Section of Eating Disorders

Institute of Psychiatry

Eating Disorders Unit

South London and Maudsley NHS Foundation Trust

Motivational Interviewing for Eating Disorders

by Professor Janet Treasure and Professor Ulrike Schmidt

One of the consistent aspects of anorexia nervosa is the denial that there is any
problem in the face of an overt signal of disease, ie starvation. This clash of
perceptions frequently leads to confrontation and coercion. It is possible that these
factors contribute to the maintenance of his problem once it has begun (the average
duration of illness is 6 years).

What do we know about the readiness to change in anorexia nervosa?

The transtheoretical model has been applied to patients with eating disorders (Ward
et al 1996; Blake et al 1997; Stanton et al 1986). Less than 50 per cent of patients
with anorexia nervosa referred to a specialist eating disorder clinic were in action;
twenty percent were in precontemplation and thirty percent in contemplation (Blake et
al 1997). The majority of patients with anorexia nervosa on an inpatient unit were in
precontemplation or contemplation (Ward et al 1996). The decisional balance and the
processes of change showed similar stage matched profiles to those found in other
conditions.

What do we know about readiness to change in bulimia nervosa?

Using the same measures, many more of the patients with bulimia nervosa were in
action. However, the situation in bulimia nervosa is more complex and fluid because
people want to stop their binges but they are much less willing to change their weight
control strategies (Blake et al 1997).
The use of Motivational Interviewing for eating disorders

The ambivalence and overt negative reaction to treatment in anorexia nervosa means
that it is a suitable case for motivational interviewing treatment. There are some case
reports (Treasure & Ward, 1997). Motivational enhancement therapy for bulimia
nervosa has been manualised (Schmidt & Treasure 1997) and is in the process of
evaluation (Treasure et al 1999). The concepts of a motivational approach for parents
are introduced in Self/Carer help guides for anorexia nervosa (Treasure 1997,
Treasure 2007). A metaphor that we use to convey the spirit of Motivational
Interviewing when we are introducing the concepts to the parents is one of Aesop's
fables. ‘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.’

An up to date account and a detailed description of this approach for eating disorders
has been included in the latest book on Motivational Interviewing (Treasure and
Schmidt 2008). The Maudsley model of individual therapy for eating disorder is
underpinned by a motivational style.
Limitations and difficulties of motivational strategies for patients with eating disorders

We have successfully introduced a motivational style of approach to all our service

setting, inpatient, day patient and out patient in our NHS unit in south London.
Nevertheless, there are some difficulties working with this patient group. The style of
Motivational Interviewing sits most comfortably when there is an equal balance of
power between client and therapist. Children and adolescents find this assumption
somewhat alien and threatening. These patients often have very low self-esteem.
They have dismissive attachment styles and avoid revealing themselves to others.
Adults are not seen as peers. In this context the therapist may need to give more
structure to the session. Commonly adolescents with anorexia nervosa are wary and
suspicious. During the information exchange process the person with anorexia
nervosa will form a judgement as to whether the therapist understands the problem.
Thus the therapist needs to subtly reveal his or her expertise. Thus in the initial phase
you need to open up avenues of eating disorder specific problems to break the ice.
One of the tenets of Motivational Interviewing is that the client is able to choose
whether he or she will decide to change. In the case of anorexia nervosa this freedom
is limited. It is physiologically impossible to choose not to eat for longer than 2-3
months. In most countries, mental heath legislation can override an individual's
decision. It is still possible to work in a motivational way if these limits are
conceptualised as part of a higher power or authority, constraining the actions of both
therapist and patients. The therapist does not have to use confrontation or coercion
directly, but can be an indirect conduit of society's rules.

Theoretical Considerations

Patents with anorexia nervosa have poor reflective functioning (a conceptual

measure, which is thought to represent metacognitive ability and is derived from the
adult attachment interview). Motivational Interviewing may work by modelling this
capacity by the therapist.

Also patients with eating disorder have an informational processing style which is
characterised by a superior attention to detail which can be at the expense of the
bigger picture. One of the key aspects of Motivational Interviewing is to step back
from the current behaviours and to see the present within the context of a life story
perspective. This reframing encourages the individual to take a more global
perspective.

Training

We run training in using motivational approaches for eating disorders. For further
details contact Gill Todd, g.todd@slam.nhs.uk.
References

Blake W, Turnbull S & Treasure JL (1997). Stages and processes of change in eating
disorders. Implications for therapy. Clin Psychol & Psychotherapy 4: 186-191.

Schmidt UH & Treasure (1997) A clinicians guide to management of bulimia nervosa

(Motivational Enhancement Therapy for Bulimia Nervosa) Psychology Press.

Stanton AL, Robert WM & Zinn LM (1986). Self change in bulimia: A preliminary
study. International J Eating Disorders 5: 917-914

Treasure J. (1997). Anorexia Nervosa. A Survival Guide for Sufferers and Those
Caring for Someone with an Eating Disorder. Psychology Press, Hove, Sussex.

Treasure, JL (2000). Motivational enhancement therapy for Anorexia Nervosa. A

companion version to escaping from anorexia nervosa. Psychology Press. Hove, East
Sussex.

Treasure, JL and Schmidt U (1997). A Clinician's Guide to Management of Bulimia

Nervosa (Motivational Enhancement Therapy for Bulimia Nervosa). Psychology
Press, Hove, Sussex.

Treasure JL and Ward A (1997). A practical guide to the use of motivational

interviewing in anorexia nervosa. European Eating Disorders Review 5: 102-114.

Treasure J, Smith G, Crane A (2007). Skills-based Learning in Caring for a Loved

One with an Eating Disorder: The new Maudsley Method. Routledge.

Treasure J, Schmidt U (2008). Motivational Interviewing in Eating Disorders. In

Motivational Interviewing and the Promotion of Mental Health. Edited by Arkowitz H,
Westra H, Miller WR, Rollnick S. New York : Guilford Press; 2008:194-224.

Ward A, Troop N, Todd G, Treasure JL (1996). To change or not to change –How is

the question. Brit J Med Psychol 69:139-146.