Finding a reason

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Publication Date: 
Thu, 2011-03-31

Exploring  motivational  interviewing as a technique for treating eating disorders

By Stephanie Cassin

Despite the proliferation of research on the treatment of eating disorders and the increased availability of empirically supported treatments in the community (e.g., cognitive behavioural therapy), eating disorders continue to have a reputation as being difficult to treat.  With these advances in mind,  you might be left wondering, “Why do some women develop chronic eating disorders that don’t seem to respond to treatment?” or “Why do some women relapse following apparently successful treatment?”  One potential explanation is that, for a variety of legitimate reasons, not all women who seek treatment for an eating disorder actually feel ready to change.  Motivational interviewing is a brief intervention that was developed with this issue in mind. 

As health care professionals, we often assume that individuals seek treatment because they are: 1) concerned about their physical or mental health, and 2) ready to make a change of some sort that might lead to alleviation of physical or emotional pain.  For example, we might assume that a woman who presents for treatment of anxiety or depression is distressed by her symptoms and is interested in learning some coping skills or taking some medication to improve her anxiety or mood.  With any luck, our assumptions turn out to be correct, treatment proceeds, symptoms are alleviated, and quality of life improves.  With even more luck, these improvements persist over time. 

The treatment of eating disorders can pose some special challenges, in part because the assumptions that we typically hold often turn out to be problematic. 

Assumption #1:

Women present for eating disorder treatment because they are concerned about their physical or mental health.
This assumption can be problematic because some women with eating disorders feel that their disordered eating behaviours are consistent with their values and self-image.  For example, a woman with anorexia nervosa might deliberately restrict her caloric intake and exercise excessively in order to achieve a low body weight, similar to the models promoted in the mainstream media.  To her, an ultra thin physique might be a sign of willpower rather than a sign of a psychological disorder.  The diagnostic criteria for the disorder specifies that individuals with anorexia “refuse” to maintain a minimally normal body weight and “deny” the seriousness of their low body weight.  Some women present for eating disorder treatment, not because they are concerned with their physical and mental health, but rather because their significant others, family, and friends are worried and/or frustrated and insist that they seek treatment.
Assumption #2:

Women who present for eating disorder treatment are ready to start making changes. 
This assumption can be problematic because even women who are concerned about their eating disorder and feel that it is important for them to change, might not feel that they are ready to make changes immediately.  Eating disorder symptoms (e.g., binge eating or excessive exercise) often serve important functions—emotion regulation, distraction, stress relief, and reward—and a woman might not feel ready to change her eating or exercise behaviours until other coping skills are in place to fulfill these important functions.  On a related note, she might lack confidence in her ability to initiate and sustain behavioural changes, particularly if she has had difficulty maintaining changes in the past.

Anyone who has had the experience of working with women with eating disorders, or with any disorder that might serve an important and valuable function, for that matter, will tell you that attempts to prescribe change for individuals who are ambivalent about change are typically met with resistance.  So, how can we put our assumptions aside and work effectively with ambivalence rather than fighting against it?

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