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Motivational Enhancement Therapy: In considering new innovative approaches to the treatment of AN, it is useful to reconceptualize the primary symptom to target in treatment. Traditionally, the symptoms that have been targeted are the behavioral concomitants of the AN patient's drive for thinness (that is, caloric restriction and other behaviors that promote weight loss). However, 1 major difficulty encountered in the treatment of AN is the AN sufferer's denial of illness and resistance to changing any of these weight-loss facilitating behaviors. It is this denial and resistance to change that has led to the AN patient's ambivalence about engaging in treatments that are focused on eliminating these egosyntonic behaviors; these symptoms are generally viewed by others as problematic and distressing but, curiously, not by the patient. It is also this denial and resistance to change that has led to the perception among clinicians that patients with AN are notoriously difficult to treat. Clinical descriptions dating back decades have noted, probably more than any other psychiatric disorder, the strong negative reactions evoked in caregivers by AN patients.
A reformulation of the disorder that specifically identifies ambivalence and resistance to change as the primary symptom in AN—which treatment has to address before any focus on behavioral change—may be helpful in devising new psychological interventions. Much can be learned about such interventions from examining other treatment-resistant populations of patients, most notably those with substance-abuse difficulties. Attitudinally, patients with AN have much in common with substance-abusing individuals. Both patient populations are commonly seen as unmotivated to change and reluctant to seek treatment volitionally. Both groups tend to alienate caregivers because of the perception that they are working against treatment rather than toward recovery. Both groups of patients tend to rationalize and deny their symptoms, and they are often perceived by therapists as deceitful. It is noteworthy that despite the central prominence of denial and resistance in the phenomenology of AN, historically, there have been relatively few attempts to rigorously measure these phenomena in AN patients, as is done in the field of substance abuse, where such disorder-specific psychometric instruments are available. More recently, investigators have developed standardized psychometric instruments that attempt to measure denial and concerns about change in AN.
Stages of Change: Because of the above-described similarities between AN and substance abuse, it is useful to consider applying to AN patients the motivational enhancement approaches that have been studied and successfully applied for years in the field of addictions. The Trans-Theoretical Model of Change, initially described by Prochaska and DiClemente in 1983, while exploring the process of change during smoking cessation, was further expanded to try to encompass and understand how individuals change problematic behaviors in general. The model describes a series of stages that individuals pass through while attempting to change such behaviors. These stages are precontemplation, contemplation, preparation, action, and maintenance.
Precontemplation. Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware of or deny their problems. When precontemplators present for treatment, they usually do so because of pressure and coercion from others. Individuals in precontemplation can wish for change, but are not seriously considering change in the near future (usually defined as within the next 6 months). Resistance to recognizing or modifying a problem is pathognomonic of the precontemplation phase. Unfortunately, for any clinician who has tried to engage and treat a patient with acute AN, this description sounds disturbingly familiar. The truth is that most patients with AN, with the possible exception of those who have been chronically ill for many years and have suffered its many negative sequelae, are in precontemplation and are not truly invested in changing behaviors that serve their drive for thinness. It is no wonder then that both acute and maintenance treatments of AN have historically been fraught with such extreme power struggles and other therapeutic difficulties. A critical step, then, in the initial phase of treatment has to address the patient's resistance and ambivalence to change before there can be a true therapeutic alliance—with the patient and caregiver both having the same agenda, which should be weight gain and eventual recovery. A psychological intervention that focuses on this important issue would make conceptual sense and would be more "client centered" than would focusing exclusively on rereading. This is what MET is designed to achieve when applied to patients with AN.
Most individuals actually move through the stages of change in a spiral rather than a linear fashion. It is expected that individuals will go through the various stages more than once before definitive change occurs and is maintained. As stated earlier, this is certainly true of people with AN, where relapse is the norm rather than the exception.
Processes of Change: The process of how individuals move from 1 stage to another is an essential dimension of the Trans-Theoretical Model of Change. Prochaska and DiClemente identified 10 processes of change. These include consciousness-raising, self-reevaluation, self-liberation, counterconditioning, stimulus control, reinforcement management, helping relationships, dramatic relief, environmental reevaluation, and social liberation. Specific processes of change correspond to each of the 5 stages of change.
Implications for Treatment: Treatment is most effective when the intervention for consideration is tailored to the patient's present stage of change. Identifying the stage of change and the corresponding processes of change associated with that stage help the therapist to determine the most appropriate and effective intervention for a particular patient. Resistance and treatment failure are the hallmark of a mismatch between the stage of change and a particular intervention. This phenomenon has certainly characterized the treatment of patients with AN, especially the intensive in-hospital treatment specifically aimed at concrete behavioral changes and weight gain.
Motivational interviewing is the therapeutic style associated with increasing intrinsic motivation in patients with addictive behaviors. The idea that motivation arises from an interpersonal process rather than preexisting in an individual, much like a trait, led to the development of the motivational interviewing technique. This approach has been found to help those who are ambivalent about change; the decision to change comes from within the patient rather than being externally imposed. Motivational interviewing complements the Trans-Theoretical Model and is especially useful for individuals in the earlier stages of change when ambivalence and resistance are prevalent. Motivational enhancement therapy is the form of psychotherapy that combines and integrates the Trans-Theoretical Model of Change and the effectiveness of motivational interviewing.
Motivational Enhancement Therapy Studies in Eating Disorders. Recently, there have been several studies using MET in treating patients with eating disorders, as well as developing eating disorder-specific instruments to assess motivation in AN and BN. Schmidt and Treasure adapted MET for eating disorders and produced a therapist's manual for use in treating these conditions. Geller and Drab developed the Readiness and Motivation Interview for Eating Disorders that can be used for clinical and research functions. Ward and others applied the Trans-Theoretical Model of Change to a group of 35 inpatients with eating disorders, 33 with AN and 2 with BN. They used 2 sets of questionnaires: 1 to assess the stage of change and the other to assess the processes used to achieve change. Most subjects were in the contemplation stage. The most frequently used processes of change were self-reevaluation, helping relationships, and consciousness-raising. Treasure and others randomized 125 patients with BN to receive 4 sessions of either CBT or MET. There were no significant differences between treatments in reducing bulimic symptoms. In a study by Feld and others, 19 eating disorder subjects, 12 of whom had full syndrome AN and 3 of whom had subsyndromal AN, were treated with 4 group sessions of MET over 4 weeks. There was a statistically significant increased motivation to change in this sample on all 3 of the motivational scales used in this study. Unanswered is the question of whether this increased motivation actually leads to better treatment outcome. There are as yet no randomized controlled trials evaluating the efficacy of MET—alone or combined with other therapies, specifically in AN—although this would be a very fruitful area to explore further.
Experiential Therapies for Anorexia Nervosa: There is a large literature on the use of experiential nonverbal therapies in the therapeutic approach to the body-image disturbance that is a core feature of AN. These include such approaches as dance-movement therapy and expressive art therapy. However, there are no published controlled trials examining the effectiveness of these approaches in patients with AN. This is surprising, considering the prominent role that these disturbances in body perception play in AN and that patients with AN have considerable difficulty labeling and verbalizing internal emotional states. The experiential creative therapies offer more direct access to unconscious and symbolic processes and to internal experiences of the body self. There is 1 study that has examined the use of guided imagery in the treatment of BN. This study randomly assigned 58 subjects with BN to either 6 weeks of guided imagery or a control condition consisting of 6 sessions reviewing subjects' personal journals that recorded eating behaviors. There was a significant decrease in binge and purge frequency in the imagery group compared with the control group. There is clearly a need to research, in a more rigorous way, the potential usefulness of such nonverbal experiential therapies in AN treatment. Finally, recent research has demonstrated the effectiveness of mindfulness-based cognitive therapy for the prevention of relapse in major depression. Such an approach would be useful to investigate in the relapse-prevention strategy of patients with AN.
Conclusions: At this time, there is little empirical evidence on which to base rational treatment decisions regarding the psychological treatments for AN. There is agreement that nutritional rehabilitation is a necessary (albeit on its own, insufficient) component of the acute treatment of AN. There is also empirical support for the use of family therapy in younger patients who have had a shorter duration of illness. There is a dire need for controlled treatment trials in AN, focusing primarily on weight maintenance, relapse prevention, and psychosocial rehabilitation. Considering that most patients will gain weight in a specialized inpatient treatment setting and that relapse and recidivism occur in most AN patients, the effectiveness of CBT and interpersonal psychotherapies alone or combined with pharmacotherapy for weight-restored patients should be the focus of future research studies. MET and possibly experiential nonverbal therapies will likely prove to be important adjunctive treatments for patients with AN. Despite the lack of empirical evidence for the effectiveness of specific individual psychotherapies in AN, clinical intuition would dictate the importance of the nonspecific factors inherent in the psychotherapeutic process for patients with a chronic and disabling illness such as AN. Warmth and genuineness, understanding and acceptance, openness and honesty are all essential components of the effective and competent long-term care of the individual psychotherapeutic approach to AN. Especially for more chronically ill patients, clinicians must be prepared to accept the possibility that their most important function is to provide genuine human contact that focuses on quality of life and removes the sense of isolation and aloneness patients feel.
Reflection Exercise #4