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Cognitive and Behavioral Practice 18 (2011) 5–15 www.elsevier.com/locate/cabp

Integrating Motivational Interviewing and Cognitive Behavioral Therapy in the Treatment of Eating Disorders: Tailoring Interventions to

Patient Readiness for Change

Josie Geller, St. Paul's Hospital, Vancouver, and University of British Columbia Erin C. Dunn, St. Paul's Hospital, Vancouver

1077 © 20 Publ

This paper focuses on the integration of Motivational Interviewing (MI) and cognitive behavioral therapy (CBT) in the treatment of eating disorders. Although CBT is regarded as the treatment of choice in this population, it nevertheless has limitations: some patients fail to engage, drop out from treatment prematurely, or simply do not improve. These are common problems in a population characterized by high levels of ambivalence about change. MI strategies can assist clinicians in enhancing readiness for change, tailoring interventions to patient readiness status, and maintaining a therapeutic alliance throughout all stages of treatment. Preliminary research examining the efficacy of adaptations of MI in the treatment of individuals with eating disorders has been promising. This paper presents 4 patient scenarios involving individuals with varying degrees of readiness and in the context of different treatment settings. For each patient scenario, key issues are described and common roadblocks to developing or maintaining a therapeutic alliance are provided. Vignettes illustrate conversations between the patient and therapist for each scenario, highlighting how MI techniques can be integrated into CBT treatment and promote a working therapeutic relationship that enhances long-term treatment outcome.

MILLIONS of individuals every year are affected byeating disorders: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Lifetime prevalence for AN is approximately 0.5% to 1% for females and .1% to .3% for males; lifetime prevalence for BN is approximately 1% to 3% for females and .5% to 2% for males; and lifetime prevalence for BED is approxi- mately 2% to 5%, with no marked gender difference (Dingemans, Bruna, & van Furth, 2002; Hudson, Hiripi, Pope, & Kessler, 2007; Striegel-Moore, 2000; Woodside et al., 2001). An even larger number of individuals suffer from what is currently categorized as Eating Disorder Not Otherwise Specified (EDNOS), which is best described as a residual category for eating disorders of clinical severity that do not meet diagnostic criteria for AN or BN (Fairburn, 2008).

Eating disorders are characterized by serious distur- bances in eating, such as binge eating, fasting, and purging (i.e., engaging in compensatory weight control behaviors), as well as subjective distress and excessive concern about body shape and weight. These behaviors are associated with a number of physical and psycholog- ical consequences. Physical consequences include amen-

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orrhea, diabetes, hypertension, damage to teeth enamel, osteoporosis, disturbances in kidney functioning, gastro- intestinal bleeding, malnutrition, bowel disease, infertil- ity, stress fractures, obesity, and cardiac arrest (Kaye, Bulik, Thornton, Barbarich, & Masters, 2004; Keel et al., 2003; Mitchell & Crow, 2006; Striegel-Moore, Leslie, Petrill, Garvin, & Rosenheck, 2000). The mortality rate for individuals with AN is the highest of any psychiatric disorder and is more than 12 times higher than the mortality rate among young women in the general population (Birmingham, Su, Hlynsky, Goldner, & Gao, 2005). Increased mortality in eating disorders is frequent- ly the result of medical complications or suicide (Birming- ham et al, 2005; Franko & Keel, 2006). Individuals with AN and BN have higher rates of mood, anxiety, and personality disorders, as well as substance abuse, com- pared to non-eating-disordered individuals (Becker, Grinspoon, Klibanski, & Herzog, 1999; Carlat, Camargo, & Herzog, 1997; Hudson et al., 2007; Stice, 1999; Woodside et al., 2001). Individuals who meet criteria for BED have been found to have higher lifetime prevalence rates of major depressive disorder, panic disorder, borderline personality disorder, and avoidant personality disorder compared to non-BED individuals (Dingemans et al., 2002; Telch & Stice, 1998). The public health burden caused by untreated eating disorders is reflected in high medical costs and loss of productivity due to

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impaired functioning. In addition, eating disorders produce significant negative psychological and social consequences for those who suffer from them, as well as for their family and friends.

Although a number of studies have provided impor- tant information about treatment for eating disorders, further research is needed to improve efficacy, cost- effectiveness, and dissemination of treatment for these disorders. Treatment is often costly (because it is delivered by highly trained specialists), can last for many months or years, and fails to produce complete remission in about half of the cases.

Treatment of Eating Disorders

Cognitive behavioral therapy (CBT) is generally regarded as the treatment of choice for eating disorders. CBT assumes that symptoms are maintained by placing a high value on attaining an idealized weight and slender shape, accompanied by inaccurate beliefs in three core domains: unrealistic expectations for body weight/shape, belief that obtaining such a weight/shape is necessary for feelings of self-worth, and inaccurate beliefs about food and how to influence weight. Thus, efforts to control shape/weight lead to strict dietary control and, subse- quently, both physical and psychological deprivation. This deprivation, in turn, can make some individuals suscep- tible to loss of control over eating. Thus, the goal of CBT for eating disorders is to establish healthy eating habits by removing the tendency to both undereat and overeat, the former thought to encourage the latter. Maladaptive attitudes about body shape and weight are also addressed. If applicable, attention is given to stopping engaging in compensatory weight control methods and relapse prevention skills are developed to help individuals resist the impulse to binge and/or purge.

Numerous studies have been conducted investigating the efficacy of CBT for BN and BED and many reviews conclude that CBT is associated with significant improve- ments in bulimic symptomatology when compared to wait-list control, other psychotherapies, and pharmaco- therapy (Fairburn, Cooper, & Shafran, 2003; Fairburn & Harrison, 2003; National Institute for Clinical Excellence, 2004; Wilson, 1999; Wilson & Fairburn, 1998). Although manual-based CBT is currently the treatment of choice for the bulimic disorders, there is little empirical support for the use of CBT for AN, or for those cases that fall within the large and heterogenous EDNOS category (Treasure & Schmidt, 2008; Waller et al., 2008). However, the transdiagnostic theory of eating disorders, which focuses on the common core pathology of patients displaying a range of disordered eating behaviors, posits that CBT addresses the processes that maintain any type of eating disorder (Fairburn et al., 2003; Fairburn, 2008). Preliminary data from Fairburn and colleagues offer some

support for this approach when treating patients who meet diagnostic criteria for AN, or those who are classified as EDNOS (Fairburn & Grave, 2008).

Treatment Dropout and Failure to Engage

Despite CBT being the most frequently used and well- researched treatment approach for eating disorders, it has limitations: many patients fail to engage in treat- ment, drop out prematurely, or simply do not improve with this approach. A number of controlled treatment trials using CBT for bulimic pathology have reported excellent short-term reductions in symptom frequency, but a 5-year follow-up study showed lasting remission from bulimic behaviors in only half of those treated (Fairburn et al., 1995). In a review of treatment dropout in the eating disorders, attrition rates from research trials ranged from 5% to 40%, with a median of 20%, and dropout rates from clinical treatment ranged from 15% to 65%, with a median of 30% (Mahon, 2000). High patient dropout and low remission or recovery rates are problems in many areas of mental health services, but are particularly prevalent among individuals with eating disorders (Mahon, 2000); many individuals with eating disorders are ambivalent about change (Vitousek, Watson, & Wilson, 1998), which can often result in a lack of engagement with therapy and premature termination.

Recent attention has been given to reasons for patient dropout from eating disorders treatment. The majority of existing studies have focused on patient characteristics that predict dropout, such as demographics, comorbid diagnoses, and severity or duration of eating disorder. However, no consistent findings link patient character- istics to treatment dropout. More recently, the focus has shifted from patient characteristics to therapy factors that predict treatment dropout. It has been suggested by a number of authors that therapeutic alliance and the interaction between eating disordered patients and therapists can have a profound effect on treatment (Geller, Williams, & Srikameswaran, 2001; Kaplan, Olmstead, Carter, & Woodside, 2001; Treasure & Schmidt, 1999; Treasure et al., 1999; Wilson, Vitousek, & Loeb, 2000). However, there has been insufficient empirical research on this topic in the eating disorders, and the research that has been conducted has been limited by a number of methodological problems (e.g., small sample size) and has yielded inconclusive results. Nevertheless, it is well recognized in other populations (e.g., substance use, depression treatment) that the therapeutic alliance and therapist factors have a pro- found impact on treatment (Barber et al., 2001; Horvath, 2001; Martin, Garske, & Davis, 2000), suggesting that these issues may also be important in the treatment of eating disorders.

7MI and CBT for Eating Disorders

Specifically, it has been suggested that understanding the match between therapist behavior and patient readiness to change may help explain why psychological treatment for eating disorders is effective for only half of those who initiate it. It is hypothesized that if the intervention and readiness to change do not match, damage will be done to the therapeutic alliance, resulting in treatment failure (Miller & Rollnick, 2002; Prochaska, DiClemente, & Norcross, 1992). Although much of the initial research on readiness to change used smoking as the problem behavior, it has been applied to a variety of health behaviors, including alcohol and drug use, gambling, exercise, sunscreen use, condom use, weight loss and obesity, and, more recently, eating disorders.

Research in the eating disorders suggests that assessing readiness to change before determining a treatment plan allows clinicians to better match patients to treatment modalities in the most cost-effective and time-efficient way possible (Franko, 1997). Moreover, readiness to change has been shown to predict weight gain, completion of activities related to recovery, dropout, relapse, and the decision to enroll in intensive eating disorder treatment (Bewell & Carter, 2008; Geller, 2002a; Geller, Cockell, & Drab, 2001; Geller et al., 2001, 2004; Reiger et al., 2000).

Application of MI to Eating Disorders

Patient dropout and noncompliance with treatment recommendations are significant problems limiting the effectiveness of many types of mental health treatments. Because failure to comply with and complete treatment can result in a number of negative consequences—most importantly, poor treatment outcome—efforts to increase compliance are under way in many areas of health behavior change. Specifically, a search to understand the critical conditions that are necessary and sufficient to bring about behavior change has begun. In other populations, research has shown that the match between patient and therapist expectations about treatment influences clients' motivation to change. For instance, a collaborative relationship between therapist and client that encompasses a shared understanding of the goals and tasks of therapy has been shown to consistently predict better client outcomes (as cited in Moyers, Miller, & Hendrikson, 2006). Conversely, a confrontational therapeutic style has been associated with higher rates of relapse than treatments using a patient-centered therapeutic style (Miller, Benefield, & Tonigan, 1993).

Similar findings have emerged in the eating disorders: collaborative treatment approaches were rated by both clients and therapists as more likely than directive treatment approaches to retain patients in treatment and to promote adherence with treatment recommenda- tions (Geller, Brown, Zaitsoff, Goodrich, & Hastings, 2003). Interestingly, in the aforementioned study, despite

participants' clear preference for collaborative interven- tions, directive interventions were rated as equally likely to occur in practice.

Motivational interviewing (Miller & Rollnick, 2002) was developed to address these treatment challenges and to enhance readiness and motivation for recovery in populations described as ambivalent about change. One of the goals of MI is to help individuals increase their level of readiness to change by combining elements of style (e.g., warmth and empathy) and technique (e.g., key questions and reflective listening). Clinician stance is considered to be critical to MI, such that the therapist uses a curious, nonjudgmental approach and shows genuine interest in the patient's experience of the problem. This is consistent with other approaches advocating the impor- tance of a curious, Socratic questioning style (e.g., Vitousek et al., 1998; Wilson & Schlam, 2004). Preliminary work on the efficacy of adaptations of MI to individuals with eating disorders has been promising (Cassin, von Ranson, Heng, Brar, & Wojtowicz, 2008; Dunn, Neighbors, & Larimer, 2006; Feld, Woodside, Kaplan, Olmstead, & Carter, 2001; Geller, Brown, Srikameswaran, & Dunn, 2006; Treasure et al, 1999).

Clinical Illustrations

One of the strengths of MI is its consideration of patient readiness in developing shared treatment goals. That is, rather than basing treatment decisions primarily or exclusively on symptom severity, motivational approaches advocate the need to assess for, and match treatment to, patient readiness. For this reason, in considering applica- tions of MI to the treatment of eating disorders, four patient scenarios involving individuals with varying degrees of readiness, and in the context of different treatment settings, will be addressed. These scenarios, which com- monly occur in clinical practice, include:

• Newly assessed patients • Patients enrolled in intensive, symptom-reduction

treatment programs • Individuals with enduring eating disorders • Individual outpatients with a fluctuating treatment

response

For each patient scenario, key issues will be described and common roadblocks to the therapeutic alliance will be provided. Clinical vignettes will be used to illustrate conversations between patient and therapist for each scenario, highlighting how MI can promote a working therapeutic relationship and enhance long-term outcome.

Newly Assessed Patients

During an initial intake assessment, forming an alliance and establishing a working therapeutic relationship is of

8 Geller & Dunn

central importance in obtaining accurate information and increasing the likelihood that the patient will return for future treatment. Interestingly, research has shown that clinicians who conduct intake assessments and who are responsible for making treatment recommendations commonly overestimate patient readiness status (Geller, 2002b). Despite presenting for an initial assessment, patients are not always ready to change their eating behaviors. They typically come to their first sessions with a number of concerns and assumptions; in some cases, they may attend the session because they are forced or coerced into doing so by a family member or partner. Some patients may fear that they will be expected to make changes for which they are not yet ready, some will be interested in feeling better but not in giving up their eating disorder behaviors, and others may wish to give up some, but not all, of their eating disorder behaviors. Therapist inaccuracy in assessing patient readiness may be due to the challenge of providing a neutral environment that conveys no expectations for change. MI offers a useful stance and questioning approach, which helps dispel patient fears about therapist expectations and increases trust in the therapist as an ally, worthy of engaging with in an honest relationship.

Common roadblocks/barriers:

• Making an assumption that the patient is ready for change

• Failing to validate the difficulties of change • Prompting the patient to talk about reasons for, but

not against, change • Having an overly rigid agenda, which conveys a

power differential and can interfere with developing a shared understanding of the problem

Example

The following encounter occurred in the context of an initial psychosocial assessment with an adolescent at a voluntary eating disorder treatment program. Prior to making treatment recommendations, the assessor met with Lisa to review her history of eating and comorbid psychiatric problems.

THERAPIST (summarizing what Lisa has said thus far): Thanks for explaining how your eating disorder devel- oped and for describing what you are currently struggling with, particularly how volatile things have been at home. It sounds like it has been really tense, especially at meal times. Is there anything else you think would be important for me to know at this time to better understand your situation and what might help you?

PATIENT: Just that everyone, especially my mom, is making a way bigger deal out of this than they need

to. I don't see what the problem is. I get my work done and I feel fine. Why can't everyone just leave me alone?

THERAPIST: Yeah… it seems like one of the biggest struggles has been dealing with others who see a problem and who are pressuring you to change something that actually feels okay for you right now.

PATIENT: Yes! I feel better than I have in a long time. I never used to like my body and I had no self-confidence. Now I like how I look; I wear cuter clothes.

THERAPIST: So there have been some real benefits to cutting back on your eating with regard to your self- esteem and body image. Are there any other advantages to the changes you have made to your eating?

PATIENT: Well, I feel healthier and I'm getting compliments from people who never used to notice me.

THERAPIST: So feeling better and getting positive attention has also been rewarding. It must be really frustrating for you when others, like your mom, give you a hard time when this is working for you in so many ways.

PATIENT: Yeah, that pretty much sums it up. I wish everyone who is hounding me about this could under- stand that.

After further discussion, including a detailed assess- ment of Lisa's medical and psychiatric risk, which are currently low, she and the therapist agreed upon a set of treatment recommendations. These included attending an outpatient group that provides information about available treatment options, explores ambivalence about change, and helps patients learn about the function that eating disorders serve. It was also recommended that she attend the program's outpatient medical clinic, to monitor her physical symptoms.

It is likely that with a patient like Lisa, attempting to convince her of change at this stage would be unproduc- tive and would make the therapist seem similar to others who have been unhelpful. A common trap is to get pulled into a confrontation where, as the therapist argues for change, the patient becomes more dogmatic about reasons for not changing. It is important to note that taking a curious stance does not preclude the therapist from informing the patient about health risks of her current behavior(s) or the benefits of normalized eating. Rather, investing time at this early stage to ensure that the patient feels that her perspective is heard, understood, and considered in making treatment recommendations increases the likelihood that she will engage in any

9MI and CBT for Eating Disorders

treatment that is offered and maintain a positive regard for the treatment team.

Patients Enrolled in Intensive, Symptom-Reduction Treatment Programs

Different issues emerge for patients who have made the decision to enroll in action-oriented, symptom- reduction treatment programs. Residential treatments typically require patients to adhere to a set of treatment nonnegotiables, or mandatory treatment components, to reduce eating disorder behaviors. In group programs the therapeutic milieu is an important factor in promoting change, as recovery among group members is enhanced by patients entering into treatment voluntarily, prepared to engage in change behavior. In such situations, patients encourage and challenge one another to work on recovery, reducing the need for the therapist to act as a cheerleader for change. Given that research has shown that long-term outcomes are more favorable when patients make the decision to enroll in treatment for themselves, as opposed to for others (Geller et al., 2004), a motivational approach can be useful in preparing such individuals for treatment, helping them to determine when they are ready to enroll and ensuring that treatment nonnegotiables are developed and enforced in a collab- orative, consistent manner.

Common roadblocks/barriers:

• Admitting patients into action-oriented treatment who are not invested in change

• Admitting patients who state that their primary reason for enrolling in treatment is for others

• Failure to acknowledge and explore ambivalence as it arises

• Nonnegotiables that have a poor rationale or are inconsistently applied

Example

The following encounter occurred in the context of a voluntary admission to a residential treatment program. Prior to entry, Greta participated in an outpatient preparatory program designed to assist patients in determining whether they are interested and willing to participate in the program, which has a number of mandatory treatment components (e.g., abstinence from bingeing and purging in the residence, minimum amount of weight gain in a specified time period). As part of the admission process Greta met with her therapist to review the program nonnegotiables and discuss those aspects of treatment that are individualized to each patient (e.g., activity protocol). The example below took place 1 week prior to a program “critical week” in which Greta is required to have gained a minimum amount of weight in order to remain in program.

THERAPIST: How did things go with your weigh-in today?

PATIENT: Umm… not that well. I didn't make my gains.

THERAPIST: Hmm… so that makes next week your “critical week.” What will that mean for you?

PATIENT: Well, it means I need to gain what I was supposed to gain this week plus what I need to gain next week, or else I'll be asked to step-out from program.

THERAPIST: So this is an important time for you. How are you feeling about all this?

PATIENT: Well, I know I have been skimping a little on weekends… and maybe exercising a little more than what my protocol says… but I didn't think I was doing that badly. I was actually surprised that with all the eating I've been doing, I hardly gained anything!

THERAPIST: Yeah… it sounds like you've been working pretty hard; you're also aware of some things that you could have done differently to increase the likelihood that you gained the necessary weight this week. What are your thoughts about next week?

PATIENT: I just don't know if I can gain that much weight! I mean… that's a lot for me! I'm already struggling with feeling fat…

THERAPIST: This really is hard work. What would it be like for you if you don't gain the weight next week?

PATIENT (softly): Well, if I don't, I will have to take the step-out and then maybe go home…

THERAPIST: (mirroring the patient's softer tone of voice): Mmm… and how would that be for you?

PATIENT: Well, I don't really want that. I mean, I have been struggling with the physical changes, but there have been some good things about being here too — having a break from my rituals and also getting some time away from my mom have been helpful.

THERAPIST: So this really is a tough situation for you: on the one hand, it would be a huge battle to make this weight gain, but on the other hand leaving program would also be difficult. What are your thoughts on where to go next?

After considering her options, Greta decided to work hard to make the necessary gains to stay in treatment. She

10 Geller & Dunn

asked her therapist to help her come up with strategies that would assist her in doing so (e.g., staying at the residence for meals on weekends instead of going home and sticking to her exercise protocol by exercising only when with a “buddy”).

This encounter illustrates the benefit of preparatory work prior to entry into treatment. Because Greta was informed about and agreed to adhere to the program non-negotiables prior to coming into the program, she was fully aware of her options, and the therapist's role was simply to assist her in choosing the best option for her at this time. The development of sound treatment nonnegotiables allows the therapist to avoid getting caught in a convincing role and instead (s)he can focus on helping the patient navigate the non-negotiables, while acknowledging that there may not be any easy or perfect choices available. Similar to the previous example, this is another situation where attempting to “cheerlead” or convince Greta to make changes may backfire and result in her actually becoming less committed to treatment.

Individuals With Enduring Eating Disorders

A particularly challenging group of patients are those with longstanding eating disorders who have made several unsuccessful treatment attempts in the past or who state that recovery is not a goal for them. Unfortunately, such patients often report a history of negative experiences with care providers and can be especially difficult to engage. These patients often present with the additional challenge of becoming medically unstable and are often unwilling to be admitted to hospital to ensure their medical safety. In dealing with such patients, it is common for conflicts to arise. MI can be extremely useful in these cases by providing a stance and set of principles that involves reviewing what hasn't worked in the past, fostering establishment of new, shared goals, and maintaining a therapeutic alliance while working with treatment nonnegotiables, or mandatory treatment components.

Common roadblocks/barriers:

• Repeating interventions/approaches that have failed in the past

• Overusing directive or threatening interventions • Failing to maximize patient autonomy • Failing to identify and work with patient higher

values • Treatment team not working together

Example

Leanne has been battling severe AN for the past 20 years. She has been repeatedly admitted to specialized intensive treatment programs. Each time, although she was

able to gain weight while in program, she immediately relapsed upon discharge. Currently, Leanne is losing weight and once again her physician is threatening certification (an involuntary treatment admission). The conversation below took place after Leanne heard this news.

THERAPIST: I understand that Dr. Chan is really worried about your health.

PATIENT: Yeah, I lost more weight last week and I've been feeling a bit light-headed lately. But it's really not that bad…

THERAPIST: So, you have some physical challenges right now, but aren't too concerned.

PATIENT: No... but I know my doctor is, because she told me that if I don't show up for outpatient meal support twice a week she will make me come into hospital.

THERAPIST: I see… so she must be thinking this is a bit more serious. This seems like a good time to check in about what you want. How do you feel about being admitted to hospital involuntarily?

PATIENT: (exasperated): I've done that so many times before and it never helps in the long run. I hate having no control over when or how the admission happens and being stuck in the hospital with no freedom… I also hate being policed all the time!

THERAPIST: Yeah… the loss of freedom can be really hard. Is there anything else that would be difficult about an involuntary admission?

PATIENT: Well, I'd have to give up everything that I care about; I wouldn't be able to do my volunteer work or finish the course that I'm taking.

THERAPIST: That does sound tough. I know you've really been enjoying your time volunteering at the daycare and that giving back to the community is really important to you. You've also said that you have wanted to finish your degree for some time now.

PATIENT: Yeah, if I dropped those things now I would be letting everyone down, with basically no warning. That is not who I want to be… and would make me feel like a failure.

THERAPIST: So getting certified would be really devastating for many reasons. How have those types of admissions gone for you in the past?

11MI and CBT for Eating Disorders

PATIENT: Well, I think it's kind of useless, since no matter how many gains I make while in hospital, it's not because of anything I am doing, you have to! So I don't have any confidence that I can maintain the changes after I leave.

THERAPIST: And what, if any, changes would you ideally like to maintain after you leave?

PATIENT: Honestly, I'd just like to avoid being certified again so that I can carry on with my life. It is so disruptive not being able to plan more than a few days ahead… but I do know that I need more energy so I can play with the kids when I'm volunteering.

THERAPIST: It sounds like what would be most helpful for you right now is to avoid being certified. Is that something you'd like to work on?

PATIENT: I guess. It's something I've never been able to do before.

In this encounter, the therapist was invested in helping Leanne avoid having another unhelpful treatment experi- ence, rather than on weight gain or other symptom change. Although at first glance it may be difficult to see the value of taking this kind of stance with a patient who is clearly on the verge of medical instability, this sort of initiative can have a profound effect on the therapeutic alliance, as well as increase the patient's feelings of autonomy and self- efficacy. These, in turn, have beneficial effects for short- and long-term treatment outcome, as the patient is more likely to engage in treatment and maintain changes over longer periods of time. In this example, the therapist was also interested in the patient's higher values, such as participating in volunteer work or completing her degree. This type of inquiry helps ensure that both patient and therapist stay connected to the patient's overarching goals and also increases trust in the therapeutic relationship.

Following this encounter, Leanne was more open with the treatment team and, over the weeks that followed, in collaboration with the rest of her care providers, Leanne and her therapist worked out a plan for her to avoid certification. This required her regular attendance at outpatient meal support twice per week and a decrease in her activity level. When a spot in the inpatient program became available, Leanne was given the option to accept a voluntary medical admission. The goals of the admission were carefully agreed upon with her prior to coming in, with a primary objective of identifying her barriers to maintaining changes after discharge. Upon discharge, Leanne reflected that this had been by far her most helpful hospital experience and was eager to continue working on improving her health.

Individual Outpatients With a Fluctuating Treatment Response

Incorporating MI into cognitive behavioral work with outpatients is useful, as there is typically a natural waxing and waning of readiness over time. Even in strong working relationships it is possible for therapists to become frustrated with patient lapses in readiness. It is also common for patients to become frustrated with therapists who persevere with skill building when the patient has slipped back a little and is wishing to address barriers to recovery.

Common roadblocks/barriers:

• Failing to recognize and/or address ambivalence when it arises

• Assuming that the patient is equally ready to change each behavior

• Focusing on skills when the patient has pressing emotional issues that need to be addressed

• Assuming that low motivation to change is exclu- sively due to lack of skill or competence

Example

The patient in the following example has BN and has been working well in therapy over the past 12 weeks. Using a CBT framework, she and her therapist have used food monitoring records to identify her triggers for binge eating and to increase her understanding of the factors that maintain her eating disorder. Over the first 10 weeks, Jane tracked her eating, purging, and exercise behaviors. Upon learning that in addition to emotional triggers, Jane also binged in response to chronic malnutrition, she increased her meal plan to include three healthy meals and two snacks each day. Whereas she was able to do this for several weeks, in the encounter described below, Jane has hit a roadblock. She states that she is feeling discouraged with her progress and questions whether she wants to continue with the work she has been doing.

THERAPIST: So, how did things go last week?

PATIENT: Well… I stuck to my meal plan and didn't purge for the third week in a row… but I don't know, maybe I'm burned out. I'm not feeling very good…

THERAPIST: Getting through another week without purging is a real accomplishment. It also sounds like things have been difficult. I'm curious about what else is going on? It sounds like there have been some struggles.

PATIENT: Well… my clothes just aren't fitting the way they used to. And I'm not imagining it. When I got weighed last week I had gained another pound. To be honest I can't help but wonder if this is all worth it.

12 Geller & Dunn

THERAPIST: Ah… you sound discouraged. Weight gain is really hard. Can you say more about that?

PATIENT: Well… before I made these changes to my eating I at least liked my body… I mean, I thought about it all the time and that was a drag… but now I can barely stand looking at myself in the mirror!

THERAPIST: So one thing you are struggling with is that there have been some changes to your body since eating more healthfully. I do remember you talking about how your physical appearance has been a source of concern for you, so that does sound difficult. It would be good for us to talk about that more. Before we do, though, I want to make sure that I get a good understanding of everything you're going through. Are there any other things that are making you wonder whether this work that you are doing is worth it?

PATIENT: Yes… I mean, I know it might not have been the healthiest way of coping, but before, when I binged, it was a total escape from the world and my problems. I always had a way to take a little vacation from everything, Now I get stressed out about something and I have to just sit with all these feelings… I don't like that! It was a lot easier before!

THERAPIST: Ah… so another huge adjustment you are going through, and a really difficult one, is that as a result of no longer bingeing you are experiencing strong feelings with no immediate escape. Can you say more about what sorts of things are bringing up these feelings?

PATIENT: Well, last week I had a few days that I worked overtime and still didn't feel like I had accomplished everything I set out to do. Also, I'm still having trouble with my boss. By the time I got home I was so tired and fed up, I just wanted to tune the world out… but couldn't.

THERAPIST: Ah… that would have been a time when in the past you would have binged. We learned that from your monitoring records.

PATIENT: Yeah…

THERAPIST: So this has been a really tough week: you are struggling with some possible physical changes and you are really missing the escape that bingeing and purging used to provide, especially when things are stressful for you at work. That's quite a lot to deal with and I'd like to help you understand those things better and figure out what is the best path for you. Before we do, though, is there anything else that you're aware of that is causing you to question continuing with treatment?

PATIENT: Ummm… No, I think those are the two main things. Well… there was one other time I was supposed to go out for dinner with a friend and she cancelled. I was feeling lonely and I wanted to binge as a way to keep myself company and pass the time…

THERAPIST: Ah… so you have also used bingeing as a way of helping pass the time when you are feeling low…

PATIENT: (nods)

THERAPIST: This really has been a difficult week. Was there anything else that you are aware of that happened to make you feel unsure about this work you are doing?

PATIENT: No. I think that's it.

THERAPIST: Well, that is certainly a lot! One option would be for us to talk about ways to help you deal with some of these body image concerns that you are having, and with missing the relief that bingeing and purging has provided… but it sounds like there is a bigger issue or concern for you, which is whether this recovery process you are going through is worth it to you.

PATIENT: Yeah, well, up until now I thought it was really hard but that I was doing well! I expected that by now, after all this time, it would get easier…

THERAPIST: So part of this is being surprised and frustrated that it's been such a tough journey…

PATIENT: Yes.

THERAPIST: Unfortunately, it is experienced that way by many people who go on to recover. You're certainly not alone in having struggles at this stage. In fact, this is a turning point for many people who have to decide whether they want to persevere when they begin encountering setbacks, even after accomplishing so much. What are your thoughts about how you would like to proceed?

PATIENT: Like I said — I just don't know if I want to keep doing this. I want my old body back!

THERAPIST: Okay, to help you make the most informed decision, how about we explore what stopping at this point would be like for you. I'm curious what you anticipate would happen…

PATIENT: Well, for one thing, I would lose weight and not feel so full all the time.

13MI and CBT for Eating Disorders

THERAPIST: And how would that be?

PATIENT: It would be great! I wouldn't feel so bad about my body.

THERAPIST: Is that how you remember things being before? That you felt good about your body?

PATIENT: Well… I guess I did still think about it a lot… and I was always trying to lose weight…

THERAPIST: Ah… so your feelings about your body may or may not improve if you stopped treatment. What else do you remember about your life when your bingeing and purging was more active?

PATIENT: Well… I did feel a little bit like my life was out of control and like I was consumed with thoughts of food all the time. That made me feel like there was something wrong with me…

THERAPIST: Hmm… those sound like hard things to cope with also…

PATIENT: They were…

THERAPIST: So this is a tough spot for you. On the one hand, things are really hard for you right now — you've made these fantastic changes but it's a lot of work and there are some consequences to it, like changes to your body.… On the other hand, going back to the way things were before is also pretty tough — you had to live with feeling out of control, consumed with thoughts of food, and even though your body may have been a little different, you still felt dissatisfied.

PATIENT: Yeah… that's true. It seems like there are no easy paths…

THERAPIST: I'm afraid not. Given the difficulty of both paths, which do you think fits best, or feels most right, for you now?

After further discussion, Jane decided that despite the challenges she was encountering she wanted to continue with therapy. After reviewing her situation further, she and her therapist decided to address some of the difficulties she was having with body image by decreasing the challenging foods she was incorporating into her meal plan and starting to work through exercises geared toward improving body image. They also focused on expanding Jane's repertoire of coping strategies, such as continuing to reach out to friends when she is lonely and experiment- ing with other ways to appropriately unwind or distract herself from some of the stresses in her life.

Had the therapist taken a different approach and instead attempted to convince Jane to remain in treatment without fully exploring Jane's difficulties and concerns, it is possible that Jane might have reacted by passively agreeing to assignments but not following through with them or by trying to persuade the therapist to see how difficult and unfulfilling change really is. Instead, Jane said she felt understood, a renewed sense of trust in her therapist, and less alone in her journey after this conversation.

Conclusions and Future Directions

A primary strength of CBT is its action-oriented nature; it seeks to identify and address the functions of eating disorder behaviors and to replace them with healthier, more adaptive functioning. The difficulty that arises is when patients are not yet ready to relinquish their eating disorder and are thus not fully engaged in this process. MI has much to contribute to CBT in these cases, as it explicitly focuses on enhancing patient readiness and maximizing treatment efficacy by ensuring that skill building occurs when the patient is most receptive. Using an MI stance ensures that treatment providers and patients are working together on shared goals, thus maintaining an alliance throughout the bumps of therapy. Although a skillful CBT therapist (or indeed practitioner of any treatment modality) may intuitively manage their pacing and interventions to patient readiness using similar strategies, MI makes these goals explicit and provides a language and set of techniques to assist in the process.

To date, the majority of research on MI in the treatment of eating disorders has focused on its use as a pretreatment to CBT or to other intensive treatment (Cassin et al., 2008; Dunn et al., 2006; Geller et al., 2006; Treasure et al., 1999). For instance, recent study results (Dunn et al., 2006; Cassin et al., 2008) suggest that the use of a brief MI add-on to self-help intervention for binge eating may be a potentially cost-effective treatment. That is, MI enhancement was shown to only slightly increase the total time of face-to-face care, but resulted in improved outcome that was comparable to that found after 4 hours of motivation enhancement therapy (Treasure et al., 1999) and 4 months of CBT (Wilfley et al., 1993). Although many of the interviewers in these studies were undergraduate or graduate research assis- tants who received only a few months of training in the theory and techniques of MI, they were nevertheless comparable to master-level therapists in participant satisfaction and adherence ratings.

MI has also been shown to have utility with individuals who have severe eating disorders. In a tertiary-care clinical setting, a brief 5-session MI-informed treatment offered following a standard intake assessment significantly reduced the number of highly ambivalent individuals

14 Geller & Dunn

posttreatment and at 3-month follow-up (Geller et al., 2006). As previous research demonstrated that these highly ambivalent individuals were more likely to drop out or relapse following intensive therapy (Geller et al., 2004), this research suggests that incorporating MI strategies into the menu of treatment options may significantly improve long-term outcome in these clinical settings, where intensive treatment is expensive (Geller et al., 2006).

Despite promising preliminary results, more research is needed to investigate the efficacy of motivational enhancement techniques as stand-alone or adjunct interventions in the treatment of eating disorders. In addition, given that motivational issues are recognized as pertinent throughout treatment in this population (e.g., Fairburn, 2008), understanding the mechanisms by which motivation develops and is maintained would also be useful. Very little is currently known about the eating disorder populations for whom MI works best. Future studies should attempt to answer this question by examining differential responding by individuals with different baseline readiness, eating disorder diagnoses and/or severity, as well as for eating disordered men. Finally, given that family members are often experienced by patients as overly directive in regards to behavior change, teaching MI techniques to family and friends of individuals with eating disorders may also be of great benefit (Treasure et al., 2007).

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This research was supported by a senior scholar grant awarded to the first author from the Michael Smith Foundation for Health Research.

Address correspondence to Erin C. Dunn, Ph.D., Eating Disorders Program, St. Paul's Hospital, Psychiatry, 1081 Burrard St., Vancouver, BC V6Z 1Y6 Canada; e-mail: [email protected].

Received: January 14, 2009 Accepted: May 3, 2009 Available online 2 April 2010