Motivational Enhancement with Eating Disorders
In this post, we look at how Motivational Enhancement Therapy can be applied to a practical situation. More specifically, we’ll discuss how counsellors can utilise this model to assist clients suffering from eating disorders.
To start, consider the Four Fundamental Principles (Lacey & Lister, unpublished) outlined below:
- The client’s drive towards thinness is ego-syntonic — it is in harmony with their goals.
- Symptom choice is driven by desperation — clients often feel there are no other options.
- Change is difficult and true empathy is difficult — reading evocative personal accounts of the disorder can help counsellors “get” this illness.
- There are reasons underpinning resistance to treatment — the counsellor is trying to change something the client regards as the solution.
Given the above principles, it is imperative that the counsellor provides validation and aims for collaboration with their client. This is achieved by acknowledging the difficulty of making changes to behaviour and by asking questions that demonstrate a knowledge and understanding of eating disorders.
In building a collaborative therapeutic relationship, the client is able to be involved in the decision making process and treatment planning. In doing this, it is always important to respect the person’s individuality — while it is reassuring to feel understood it can be offensive to be stereotyped, therefore the counsellor needs to avoid comments such as: “all anorexics feel like this”, or “Like other bulimics, I bet you?”.
Instead the counsellor should choose comments such as: “Everyone is different”, and “I don’t know what it’s like for you but some of my clients have said?”
In motivational enhancement, any arguments for change should come from the client, not the counsellor. The natural expected outcome of a counsellor making an argument for change is that an ambivalent client will argue against it.
A client becomes more committed to what they hear themselves saying, so if the counsellor causes a client to argue against the need for change, they are being moved in the wrong direction.
For example, when asking “On a scale of 0 to 10, how important is it for you to change your eating behaviour?” the follow-up question would be “Why are you at a 5 and not 0?” The answer to this is the reason for change. Asking the more obvious question “Why are you a 5 and not a 10?” is not motivational because the answer to this question provides reasons against change.
Expressing Empathy — This initial step seeks to understand the person’s feelings and perspectives without judging, criticising or blaming. The counsellor simply accepts the person’s ambivalence about change as a normal part of human experience, i.e. reluctance to give up a problem behaviour is to be expected.
Developing Discrepancy — Change is motivated by the size of the discrepancy between where a person is and where they want to be. The bigger the discrepancy, the stronger the motivation is for change.
This approach often utilises the “Colombo approach” where the counsellor plays detective, investigating a mystery where the clues don’t add up and engaging the client in the process to help solve the mystery. This process encourages the person to recognise reasons for change. A number of strategies can be useful at this stage:
- Future projection: exploring how the eating disorder interferes with the client’s future goals.
- Looking back: exploring the strengths from the client’s life prior to the onset of the eating disorder.
- Explore extremes: loosening the client’s attachment to their eating disorder by exploring their worst fears, e.g. “What are the worst things that could happen to you if you keep behaving the way you have been?”
- Respectful information provision on the negative consequences of the eating disorder.
- Juxtaposition of the person’s statements, eg. “Your aim is to have a fit healthy body, yet you frequently skip meals and haven’t had a period for months. I’m not sure how these go together?”
- Externalise the disorder: this is a process of separating out the illness from the person and can be done through talking to or writing letters directly to the eating disorder.
Rolling With Resistance — There are four types of resistance:
- Arguing: the person contests the accuracy, expertise or integrity of the counsellor.
- Interrupting: the person interrupts the counsellor in a defensive manner.
- Denying: the person expresses unwillingness to recognise problems, cooperate or accept responsibility.
- Ignoring: the person shows signs of ignoring or not following what the counsellor is saying.
In motivational enhancement, arguments are considered counterproductive because defending breeds defensiveness. Client resistance is viewed as a signal to change strategy because direct persuasion is not considered an effective means for resolving resistance.
Arguments are not rejected but reframed, so that new perspectives are suggested rather than imposed on the person.
Supporting Self-Efficacy: This step involves supporting the person’s belief in their ability to succeed in changing behaviour. The counsellor encourages the person to remember any achievements they may have had in the past.
They also assist the person to develop an internal locus of control by encouraging personal responsibility for change, rather than attributing change to external factors outside their control (an external locus of control).
Another important step towards increasing a client’s self-efficacy is to introduce doubt about the beliefs that keep them stuck. The counsellor should first validate these beliefs by showing they understand that change is difficult and that such beliefs hold an adaptive function for them, i.e. it protects the person from confronting change too quickly before they are ready.