readiness to change, predictor to treatment outcome

1Wednesday, April 23, 2008

Presentation


background & Study 1

study 2

general discussion & discussion question


you can drag a donkey to the water,but you can’t force it to drink.

you can bring them to the hospital

but do they want to be treated?


recovery rate


50% recover

what about the rest?


don’t make it


1

2

3

4

Get well

Relapse immediately

gradual get better

gradually get worse


demog

raphic

, pers

onali

ty, fam

ily

Sympto

ms seve

rity, so

cial s

uppo

rt, de

mograp

hic

family

functi

oning

self-e

steem

, sympto

ms, pers

onali

ty

family,

perso

nality

demog

raphic

, sympto

ms

perso

nality

sympto

ms

read

iness

& mot

ivatio

n

read

iness

& mot

ivatio

n

read

iness

& mot

ivatio

n

read

iness

& mot

ivatio

n

1991

1992

1995

1996

1997

1999

2000

2001

1998

2004

Treatment outcome predictors


What is change?


Willingness to change

Abi

lity

to c

hang

e

ACTUAL CHANGE


PrecontemplationComtemplationPreparationAction

Maintenance

Termination


How to assess Readiness to Change?


Stage of Change Questionaire


Willingness to change

Abi

lity

to c

hang

e

ACTUAL CHANGE

Precontemplation/Contemplation

Act

ion/

Mai

nten

ance


Study 1


Prec

onte

mpl

atio

n

1

Con

tem

plat

ion

2

Act

ion

3

Inte

rnal

ity S

core

s

4

Restriction

Compensatory Strategies

Cognitive/Affective

Bingeing

Symptoms Domain


64Duration 10.9 years on average

AN BMI = 16.8 BN BMI = 19.9

Average age of 26.9

35 AN

37 BN


AN Restricting SubtypeAN binge-purge subtypesubthreshold ANBulimia Nervosa

64


64 enroll

drop out

Readiness

&

Motivation

Interview

Domain Scores


Type Outcome

Unwilling & High Restriction Less lightly to enroll

Unwilling & High Compensation Less lightly to enroll

High Action More lightly to enroll

Unwilling & High Restiction More lightly to drop out

Unwilling & High cognition Less lightly to enroll


Result

• "Findings suggest that both the decision to enroll in treatment and dropout from treatment, were predicted by more than one subscale and by more than one symptom domain. However, only restriction precontemplation significantly predicted both outcome variables.”


Study 1


Purpose of Study II

• Study II examined the relationship RMI / EDI subscale domain and clinical outcome post treatment and 6 months follow up


STUDY 2: post and 6 months follow-up outcomes

• Participants : 60 women (48 from Study 1 and additional 12

• Patients receiving intensive treatment in a Canadian eating disorder programs

• Diagnoses were assigned using the same procedure and criteria as Study 1

• Mean duration of ED : 12.1 years

• Mean BMI for AN : 16.8 and BMI 21.1 for the rest of the sample

• Average Age : 28.4 years

• SES (socioeconomic status 2.2) Upper middle class


AN Restricting SubtypeAN binge-purge subtypeED not otherwise Specified (EDNOS)Bulimia Nervosa

Participants Classification


Discovery

• Eating Disorder Inventory 1



• Eating Disorder Inventory C


• The researchers use use the Readiness & Motivation Interview (RMI)

• The Eating Disorders Inventory II (EDI-2)

• 91 item self-report questionnaire to measure attitudes, personality features and ED symptoms relevant to AN & BN.

• Measures : Attitudes

• Personality Features

• Eating Disorders Symptoms associate with BN & AN

MEASURES


Study 2 also measure the relationship between the willingness to change for themselves VS others (Internality) and the drive for thinness (DT) and body dissatisfaction (BD).

On a 6 points scales ( Never to Always)

MEASURES


• Participants at post treatment have less power to change their diets thus, BMI was not a reliable indicator of ED symptoms for post treatment.

• BMI was used for the 6 months follow up because they have better changing their diets

ProcedureMEASURES


• “Not willing to change” predicted increase in DT and BD

• “Wanting to take actions” predicted reduce in BD

• “Willingness to change” is insignificant in predicting DT and BD

POST TREATMENT


• Ex-ED patients show “More willing to change”, and “more desire to change for themselves”.

• Current ED patients with “More unwilling to change” and “less desire to change for themselves”.

• Current ED patients score higher level in DT & BD compared to Ex-ED patients

6 MONTHS FOLLOW UP


• Post Treatment : Restriction Precontemplation, “not willing to change” is a good prediction for short term clinical outcome

• 6 Months Follow Up : Internality, “Willingness to change for oneself” is important and strongly related to drive to thinness and maintenance of healthy body weight

• Finally , assessing client readiness and motivation to change dietary is very useful to predict short term and long term clinical outcomes

CONCLUSION OF STUDY 2


... ... ....


General Discussion


• Many challenging obstacles in treating ED

• Identification of predictive characteristics

• Focus on readiness and motivation

• Lack of readiness and motivation to change restrictive eating is key in predicting treatment outcomes

• Not wanting to change restrictive eating (restrictive precontemplation)

• Changing restrictive eating for oneself (restrictive internality)

General Discussion


• Small sample size

• Attrition for 6-month follow up

• Inability to include bingeing domain

Research LimitationsResearch Limitations


“… the development and evaluation of interventions that enhance readiness to change restriction and internality

would likely be of benefit.”

Parting Words of Geller et al (2004)


What kind of interventions can enhance readiness to change restriction and

internality?

Discussion Question


What kind of interventions can help ED individuals to want to change

restrictive eating and to change for themselves and not others?”

In Other Words


Motivational Enhancement

Therapy(MET)


• Systematic intervention approach based on motivational psychology for effecting internally-motivated change

• Adopts Transtheoretical Model of Change

• Combines motivational interviewing (MI) with personal assessment feedback

• Typically consists of 4-12 sessions

Manuals available in the public domain – for alcohol and drug

abuse

Motivational Enhancement Therapy (MET)‏


• Express Empathy

• Develop Discrepancy

• Avoid Augmentation

• Roll with Resistance

• Support Self-Efficacy

Where they are

Where they want to be

Discrepancy

General Principles of MET


Reflective ListeningTHERAPIST: What else concerns you about your drug use?

CLIENT: Well, I'm not sure I'm concerned about it, but I do wonder sometimes if I'm using too much.

T: Too much for . . .

C: For my own good, I guess. I mean it's not like it's really serious, but sometimes when I wake up in the morning I feel really awful, and I can't think straight most of the morning.

T: It messes up your thinking, your concentration.

C: Yes, and sometimes I do stupid things.

T: And you wonder if that might be because you're using too much.


• Express Empathy

• Develop Discrepancy

• Avoid Augmentation

• Roll with Resistance

• Support Self-Efficacy

Where they are

Where they want to be

Discrepancy

General Principles of MET


"The sun and the wind were having a dispute as to who was the most powerful. They saw a man walking along and they challenged each other about which of them would be most successful at getting the man to remove his coat.

The wind started first and blew up a huge gale; the coat flapped but the man only closed all his buttons and tightened up his belt.

The sun tried next and shone brightly making the man sweat. He proceeded to take off his coat.“

Aesop Fable

Analogy of the Spirit of METAnalogy of the Spirit of MET


MET Confrontational Methods

Gentle persuasion, enhance discrepancy

Coerce, break down denial

Does not label Imposes diagnostic labelSupportive companion and

consultantExpert, superior/inferior

Personal choice, self-motivational statements

Must do or must change

Self-efficacy (ability to change) PowerlessnessBuilds motivation and elicits

ideasTeach specific coping skills


• Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (Hettema, Steele & Miller, 2004)

• 72 studies over many domains (mostly alcohol, drug abuse, only 1 ED)

• Conclusions

• Robust and enduring effects when MI is added at the beginning of treatment

• The effects of motivational interviewing emerge relatively quickly

• The between-group effects of motivational interviewing tend to diminish over 12 months

• The effects of MI are highly variable across sites and providers

Evidence Support


• MET is an effective first phase of treatment for BN (Treasure, 1999)

• MET increases participants’ motivation to change, decreases depressive symptoms and increases self-esteem (Feld et al, 2001)

• Motivational enhancement therapy for Bulimia Nervosa manual (Schmidt & Treasure, 1997)

• Motivational enhancement therapy for Anorexia Nervosa. A companion version to escaping from anorexia nervosa. (Treasure, 200?)

MET and EDMET and ED


• MI style may be alien or too unstructured for adolescent ED patients

• MI principle of allowing choice (to eat or not to eat) may go against physical realities or country legislature

• Family might sabotage efforts by using confrontational style at home

• Staff may not be able to maintain motivational style at work constantly

• The superiority of motivational approaches over traditional approaches for patients at precontemplation and contemplation has yet to be proven conclusively for ED (Treasure & Schmidt, 2001)

Challenges in Adapting MET for ED


• Keeping in view its challenges and limitations, MET can be used to enhance ED patients’ readiness to change restriction and internality

Answer to Discussion QuestionAnswer to Discussion

Question


• Please focus your questions and discussion to the following areas:

• Readiness to change dietary restriction predicts outcomes in the eating disorders, Geller et al (2004)

• What kind of interventions can help to enhance readiness to change restriction and internality?

Discussion Time Discussion Time


readiness to change, predictor to treatment outcome

Health & Medicine

background study

recovery rate