Decisional balance in anorexia nervosa: capitalizing on ambivalence

Users' perceptions of how an unmoderated eating disorder community may benefit or harm their recovery

BACKGROUND

While the negative and positive outcomes of pro-eating disorder groups have been well-documented, more research is needed on the effects of pro-recovery communities. In particular, a gap in knowledge remains surrounding users' feelings about their experiences in such communities. Using open-ended questions, we surveyed those involved in the recovery community on the social media site Tumblr, to determine how the community helped/did not help with recovery, and how it made them feel about recovery.

METHODS

Participants (n = 29) answered a series of Likert and open-ended questions. The open-ended questions were examined using thematic analysis to learn about users' lived experiences.

RESULTS

Themes identified included connection/acceptance, motivation/encouragement, content, and competition/comparisons. Participants overall felt that the community helped them feel connected to others and accepted for their struggles and their successes, though a minority did note that such acceptance could sometimes reinforce negative behaviors, and connection could lead to pressure to help others. Participants found both direct advice and indirect support (e.g., encouraging posts) to be motivating for their recovery. Feelings of competition and comparison were mixed; some felt that comparing to others made them feel less than, while others used such comparisons as reminders to stay strong in recovery. Participants indicated that the content within the community varies; sometimes there is a large presence of pro eating disorder posts, while at other times, posts are more positive, motivational, and encouraging.

CONCLUSIONS

Participants overall indicated that the community had many helpful aspects and made them feel better about recovery. However, the presence of triggering content and competition in particular were notable drawbacks of the community. Overall, recovery communities on unmoderated sites or social media applications may be useful tools during the recovery process, despite some important limitations.

The Role of Emotion Regulation in Eating Disorders: A Network Meta-Analysis Approach

Background

Previous theoretical models and reviews have documented a strong connection between emotion dysregulation eating disorder (ED) psychopathology among the general and clinical populations. The aim of this review was to build on this previous work by conducting a network meta-analysis to explore associations between adaptive and maladaptive emotion regulation strategies and ED psychopathology trans-diagnostically across the ED spectrum to identify areas of emotion dysregulation that have the strongest association with symptomatology.

Methodology

A total of 104 studies were included in the meta-analysis and correlation coefficient representing the associations between specific emotion regulation strategies and ED symptomatology were extracted. We ran a Bayesian random effects network meta-analysis and the initial network was well-connected with each emotion regulation strategy being linked to at least one other strategy. We also conducted a network meta-regression to explore whether between-study differences in body mass index (BMI), age, and whether the sample consisted of solely female participants explained any possible network inconsistency.

Results

The network meta-analysis revealed that ruminations and non-acceptance of emotions were most closely associated with ED psychopathology. There was no significant network inconsistency but two comparisons approached significance and thus meta-regressions were conducted. The meta-regressions revealed a significant effect of BMI such that the associations between different emotion regulation strategies and ED symptomatology were weaker among those with low BMI.

Discussion

The present findings build on previous work and highlight the role of rumination and difficulties with accepting emotions as key emotion regulation difficulties in EDs. Additionally, the finding that the associations were weaker among ED patients with low BMI may point toward a complex relationship between ED behaviors and emotion regulation. Taken together, our findings call for interventions that target emotion regulation, specifically rumination and difficulties accepting emotions, in the treatment of EDs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021249996, PROSPERO, identifier: CRD42021249996.

Why would I want to be more self-compassionate? A qualitative study of the pros and cons to cultivating self-compassion in individuals with anorexia nervosa

OBJECTIVE

Although self-compassion facilitates eating disorder symptom remission, individuals with eating disorders are fearful of developing it and higher fears of self-compassion are associated with poorer treatment outcomes. In-depth exploration of individuals' pros and cons of behaviour change is generally helpful at resolving ambivalence; however, no research has examined the pros and cons individuals with eating disorders perceive to be associated with developing self-compassion, limiting our understanding of their personal experiences when confronted with self-compassion. Given the research suggesting higher resistance to self-compassion development in individuals with anorexia nervosa (AN), the present study used qualitative methods to gain a deeper understanding of their perceived pros and cons to self-compassion.

METHODS

Thirty-seven women with typical (64%) and atypical (36%) AN signed up for a study on self-help strategies for daily distress. Upon learning that the intervention would entail cultivating self-compassion, they identified their perceived pros and cons of developing self-compassion by typing them out.

RESULTS

Thematic analysis was used to extract themes. Three superordinate cons and four superordinate pros of self-compassion emerged. Perceived cons were as follows: self-compassion leading to personal shortcomings; apprehension and doubt about the efficacy of self-compassion; and emotional challenges associated with developing self-compassion. Perceived pros were as follows: improved health; personal development (e.g., growth, coping); improved outlook; and enhanced social relationships.

CONCLUSIONS

These findings reveal the various advantages and disadvantages that women with AN perceive to be associated with developing self-compassion. Results may help clinicians work more sensitively and effectively when trying to cultivate self-compassion in patients who have AN.

PRACTITIONER POINTS

This research suggests that patients with anorexia nervosa (AN) perceive various disadvantages to cultivating self-compassion, but also certain advantages. By familiarizing themselves with the pros and cons to self-compassion identified by individuals with AN, clinicians may be able to more effectively listen to and communicate with their patients about ambivalence about self-compassion development. Clinicians may want to listen for and explore concerns in their AN patients that self-compassion will lead to personal shortcomings, fail to be beneficial, and be emotionally challenging. Clinicians may want to listen for and help patients elaborate upon their beliefs about how self-compassion might benefit their outlook, health, personal development, and relationships.

Cutting Ties With Pro-Ana: A Narrative Inquiry Concerning the Experiences of Pro-Ana Disengagement From Six Former Site Users

Websites advocating the benefits of eating disorders ("Pro-Ana") tend to reinforce and maintain restrictive eating and purging behaviors. Yet remarkably, no study has explored individual accounts of disengagement from these sites and the associated meanings. Using narrative inquiry, this study sought to address this gap. From the interviews of six women, two overarching storylines emerged. The first closely tied disengagement to recovery with varying positions of personal agency claimed: this ranged from enforced and unwelcomed breaks that ignited change, to a personal choice that became viable through the development of alternative social and personal identities. A strong counternarrative to "disengagement as recovery" also emerged. Here, disengagement from Pro-Ana was storied alongside a need to retain an ED lifestyle. With "recovery" being just one reason for withdrawal from Pro-Ana sites, clinicians must remain curious about the meanings individuals ascribe to this act, without assuming it represents a step toward recovery.

Improving motivation to change amongst individuals with eating disorders: A systematic review

OBJECTIVE

People with eating disorders can have low motivation to change their eating disorder behaviors. Interventions aiming to enhance motivation to change have been increasingly advocated in their treatment. Questions remain regarding the strength of the evidence supporting the effectiveness of interventions that specifically focus on improving motivation. This review explored the evidence for improving motivation to change in eating disorders via clinical interventions.

METHOD

Searches of the published and unpublished literature were conducted by searching databases (PubMed, PsychInfo, Web of Science) and trial registries (WHO ICTRP), and by contacting authors. Studies were included if they investigated an intervention for eating disorder patients, included a pre-post outcome measure of motivation to change and were published in English. Risk of bias was also assessed.

RESULTS

Forty-two studies were included in the final review. Evidence was found to support the use of interventions to improve motivation to change, though it was unclear whether motivational interventions present a more effective option than approaches that do not exclusively or specifically focus on motivation. However, motivational interventions were identified as being more effective than low intensity treatments. Risk of bias in included studies was generally high.

DISCUSSION

Motivation was found to increase across treatments in general, whether or not the focus of the intervention was on enhancing motivation. It is unclear if interventions specifically targeting motivation to change provide additional benefit over and above established treatment approaches.

Contingency Contracts for Weight Gain of Patients with Anorexia Nervosa in Inpatient Therapy: Practice Styles of Specialized Centers

The treatment of patients with anorexia nervosa (AN) is often challenging, due to a high degree of ambivalence towards recovery and weight gain these patients often express. One part of the multimodal treatment is the utilization of treatment contracts (i.e., contingency contracts) that aim to motivate patients to gain weight by applying positive and negative consequences for the (non-)achievement of weight goals. The main aim of this study is to assess and analyze current standards of contingency contracts’ utilization in German eating disorder centers. n = 76 mental health professionals of twelve specialized university centers in Germany that are currently or were formerly treating patients with AN in an inpatient setting participated. Most experts use contingency contracts in their clinic with weekly weight goals ranging between 500 and 700 g. Overall effectiveness and significance of contingency contracts for the inpatient treatment of patients with AN was rated high. Typical characteristics of a contingency contract in specialized German university hospital centers, such as the most frequent consequences, are described. The survey results assist the planning of further studies aiming to improve the multimodal treatment of patients with AN. For clinical practice, using external motivators such as contingency contracts as well as targeting internal motivation (e.g., by using motivational interviewing) is proposed.

Not Eating or Tasting Other Ways to Live: A Qualitative Analysis of 'Living Through' and Desiring to Maintain Anorexia

Whilst recent discussions of anorexia nervosa have recognised key aspects of the illness experience, such as control and emotion regulation, there remains a cross-disciplinary emphasis on body image concerns as central. In dialogue with clinical, psychological and social analyses, this paper draws on ethnography and qualitative interviews with individuals diagnosed with anorexia to offer an alternative perspective. Focusing on individuals' engagements with food and (not) eating suggests that material moments of starving, calorie counting, and thinking about food provide a critical lens onto what anorexia does for, as well as to, individuals living with the illness. Participants' narratives suggest that anorexia can make it possible to retreat into a numb and protective 'bubble.' The illness may thereby offer a way to be in the world that both responds to and ameliorates distress; some individuals describe the ambivalent 'safety' of living through their anorexia. As such, food practices are a modality of holding onto anorexia's valued safety. By outlining this relationship between practices of (not) eating and a desire amongst some individuals to maintain the illness, this paper contributes to discussions of treatment resistance. Intersecting with wider reflections on trauma, recovery and harm minimisation in mental health, the discussion considers how this desire might be approached ethically in both research and therapeutic practice. Individuals' narratives suggest the need to reposition attention away from anorexia itself to the distress and traumatic life events that may underlie both the illness and the desire to maintain it.

The effectiveness of contingency management in the treatment of patients with anorexia nervosa: A systematic review

Contingency management in stipulating weight gain is routinely used in the treatment of anorexia nervosa, however, empirical investigations concerning its effectiveness have been scarce. This systematic review was conducted according to the PRISMA statement. Of N = 973 hits, 42 full-texts were included in the qualitative synthesis (11 theoretical texts, 19 case reports, 12 descriptive, cohort, and controlled trials). A central topic in the included publications concerns the enhancement of patients' autonomy through participation in the contingency management process. This heightened autonomy is achieved by using contingency contracts. Positive short-term effects on weight gain were shown, whereas follow-up results were heterogeneous. Although contingency contracts are widely used in clinical practice, our systematic review shows that empirical evidence on underlying mechanisms and efficacy is still scarce. Using an explicit treatment contract can enhance patients' motivation, compliance, and autonomy. Clinical practice should see further development including innovative motivation enhancing and conflict dissolving techniques in addressing the pronounced ambivalence often shown by patients with anorexia nervosa.

The Egosyntonic Nature of Anorexia: An Impediment to Recovery in Anorexia Nervosa Treatment

A serious problem faced by clinicians treating anorexia nervosa is the egosyntonic nature of the illness, wherein individuals with anorexia nervosa value their disorder, thereby hindering motivation for recovery and engagement with treatment. The objective of this review article is to elucidate the nature of egosyntonicity in anorexia nervosa, reviewing both qualitative and quantitative research pertaining to this topic, and, importantly, to present methods to overcome this impediment to recovery in anorexia nervosa treatment. The authors elucidate functions of anorexia nervosa for patients, both within psychological and social spheres, as well as highlight the detrimental effect of egosyntonicity in terms of illness severity and motivation for recovery. The final part of the paper contains suggestions as to methods of bypassing pitfalls linked with the influence of the egosyntonic nature of anorexia nervosa within a treatment setting, as well as an examination of three current treatments (enhanced cognitive-behavioral therapy for eating disorders, Maudsley Model of Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management) in terms of the degree to which they target egosyntonicity.

MotivATE: A Pretreatment Web-Based Program to Improve Attendance at UK Outpatient Services Among Adults With Eating Disorders

Background

In the UK, eating disorders affect upward of 725,000 people per year, and early assessment and treatment are important for patient outcomes. Around a third of adult outpatients in the UK who are referred to specialist eating disorder services do not attend, which could be related to patient factors related to ambivalence, fear, and a lack of confidence about change. This lack of engagement has a negative impact on the quality of life of patients and has implications for service costs.

Objective

To describe the development of a Web-based program (“MotivATE”) designed for delivery at the point of referral to an eating disorder service, with the aim of increasing service attendance.

Methods

We used intervention mapping and a person-based approach to design the MotivATE program and conducted a needs assessment to determine the current impact of service nonattendance on patients (via a review of the qualitative evidence) and services (through a service provision survey to understand current issues in UK services). Following the needs assessment, we followed the five steps of program development outlined by Bartholomew et al (1998): (1) creating a matrix of proximal program objectives; (2) selecting theory-based intervention methods and strategies; (3) designing and organizing the program; (4) specifying adoption and implementation plans; and (5) generating program evaluation plans.

Results

The needs assessment identified current nonattendance rates of 10%-32%. We defined the objective of MotivATE as increasing attendance rates at an eating disorder service and considered four key determinants of poor attendance: patient ambivalence about change, low patient self-efficacy, recognition of the need to change, and expectations about assessment. We chose aspects of motivational interviewing, self-determination theory, and the use of patient stories as the most appropriate ways to enable change. Think-aloud piloting with people with lived experience of an eating disorder resulted in positive feedback on the MotivATE program. Participants related well to the stories used. Nonetheless, because of feedback, we further modified the program in line with patients’ stage of change and addressed issues with the language used. A consultation with service staff meant that we could make clear implementation plans. Finally, a randomized controlled trial is currently underway to evaluate the MotivATE program.

Conclusions

Using intervention mapping, we have developed a novel pretreatment Web-based program that is acceptable to people with eating disorders. To our knowledge, this is the first such program. The model of development described here could be a useful template for designing further programs for other difficult-to-engage populations.

Differences in physical status, mental state and online behavior of people in pro-anorexia web communities

BACKGROUND

There is a debate about the effects of pro-anorexia (colloquially referred to as pro-ana) websites. Research suggests that the effect of these websites is not straightforward. Indeed, the actual function of these sites is disputed, with studies indicating both negative and positive effects.

AIM

This is the first study which systematically examined the differences between pro-anorexia web communities in four main aspects: web language used (posts); web interests/search behaviors (queries); users' self-reported weight status and weight goals; and associated self-reported mood/pathology.

METHODS

We collected three primary sources of data, including messages posed on three pro-ana websites, a survey completed by over 1000 participants of a pro-ana website, and the searches made on the Bing search engine of pro-anorexia users. These data were analyzed for content, reported demographics and pathology, and behavior over time.

RESULTS

Although members of the main pro-ana website investigated appear to be depressed, with high rates of self-harm and suicide attempts, users are significantly more interested in treatment, have wishes of procreation and reported the highest goal weights among the investigated sites. In contrast, users of other pro-ana websites investigated, are more interested in morbid themes including depression, self-harm and suicide. The percentage of severely malnourished website users, in general, appears to be small (20%).

CONCLUSIONS

Our results indicate that a new strategy is required to facilitate the communication between mental health specialists and pro-ana web users, recognizing the differences in harm associated with different websites.

A factor analysis of the meanings of anorexia nervosa: intrapsychic, relational, and avoidant dimensions and their clinical correlates

BACKGROUND

Anorexia nervosa (AN) is a difficult to treat disorder characterized by ambivalence towards recovery and high mortality. Eating symptomatology has a sort of adaptive function for those who suffer from AN but no studies have to date investigated the relationship between the reported meanings of AN and patients' clinical characteristics. Therefore, we aimed to perform a factor analysis of a new measure testing its psychometric properties in order to clarify whether subjective meanings of AN can be related to AN severity, to ascertain if some personality traits correlate with the meanings attributed to AN by patients, and finally to verify to what extent such meanings relate to patients' duration of both illness and treatment.

METHODS

Eighty-one inpatients affected by AN were recruited for this study and clinical data were recorded. Participants were asked to complete a novel instrument, the Meanings of Anorexia Nervosa Questionnaire (MANQ) focused on the measurement of values that patients attribute to AN and other measures as follows: Eating Disorders Inventory-2, Beck Depression Inventory, Temperament and Character Inventory, and Anorexia Nervosa Stages of Change Questionnaire.

RESULTS

As measured by the MANQ, body dissatisfaction, problems of adolescence, and distress at school or work mainly triggered the onset of AN. Balance and self-control were mostly reported as meanings of AN while the most frequent negative effects were: being controlled by the illness, obsessive thoughts about body shape, and feeling alone. Differences were found between diagnostic subtypes. When a factorial analysis was performed, three factors emerged: intrapsychic (e.g., balance/safety, self-control, control/power, way to be valued), relational (e.g., communication, way to be recognized), and avoidant (e.g., the avoidance of negative feelings, emotions, and experiences). These factors correlated with patients' personality and motivation to treatments but were unrelated to duration of both illness and treatments.

CONCLUSIONS

Given the ego-syntonic nature of AN, the understanding of patients' value of their disorder could be relevant in treatment; moreover, the positive value of AN resulted to be unrelated to the duration of both illness and treatments. Future research is warranted to replicate these findings and test their clinical implications.

Experiential acceptance, motivation for recovery, and treatment outcome in eating disorders

PURPOSE

This study sought to test whether the relationship between experiential acceptance (EA) and treatment outcome among eating disorder (ED) patients was mediated by motivation.

METHODS

Upon admission to a residential ED treatment facility, female patients completed measures of EA, motivation, and baseline ED symptom severity (covariate); symptom severity was reassessed at discharge.

RESULTS

Higher levels of baseline EA predicted significantly greater symptom reduction during treatment. Moreover, results from bootstrapped mediation analyses indicated that the relationship between EA and treatment outcome was partially mediated by motivation: increased EA was associated with greater motivation to give up ED behaviors at the beginning of treatment, and this led to greater symptom reduction from admission to discharge.

CONCLUSIONS

Motivation appears to be one mechanism by which EA facilitates improved treatment outcomes in EDs. Further development of interventions that promote EA as a means for improving motivation and subsequent ED treatment response may be warranted.

Partner distress in the context of adult anorexia nervosa: the role of patients' perceived negative consequences of AN and partner behaviors

OBJECTIVE

Romantic partners can play an important role in the recovery from anorexia nervosa (AN). It is important to understand partners' behaviors and variables associated with their own distress. The aim was to examine associations of patients' perceived negative consequences of AN, behavioral strategies employed by partners, and partner distress.

METHOD

We used a cross-sectional design to assess associations between self-reports of patients' perceived negative consequences of AN, partners' caregiver distress, negative affect, relationship satisfaction, and observational coding measures of partners' behavioral strategies of change promotion and acceptance/validation. Sixteen adult patient-partner dyads in committed relationships were assessed at baseline of a couple-based intervention for AN.

RESULTS

Partners' change promotion moderated the association between patients' perceived negative consequences of AN and partners' caregiver distress. Partners' acceptance/validation was associated with partners' negative affect.

DISCUSSION

This report represents the first description of specific partner behaviors in the context of AN. Partners who reported the least distress were those who were trying to promote changes in AN behaviors in patients who reported high negative consequences of AN, and partners who were trying to show understanding of the patients' experience. Future studies should examine the impact of partner behaviors on AN treatment outcome.

An Internet-based program to enhance motivation to change in females with symptoms of an eating disorder: a randomized controlled trial

BACKGROUND

Previous research has demonstrated an association between low motivation to change and an unfavorable treatment outcome in patients with an eating disorder. Consequently, various studies have examined the effects of motivational enhancement therapy (MET) on motivation to change and treatment outcome in eating disorders. In each of these studies, MET was administered in a face-to-face setting. However, because of its anonymity and ease of access, the internet provides several advantages as the format for such an intervention. Therefore, the current study investigated the effects of an internet-based program ('ESS-KIMO') to enhance motivation to change in eating disorders.

METHOD

In total, 212 females were accepted for participation and assigned randomly to the intervention condition (n = 103) or waiting-list control condition (n = 109). The intervention consisted of six online MET sessions. Before and after the intervention or waiting period respectively, participants completed the Eating Disorder Examination Questionnaire (EDE-Q), the Stages of Change Questionnaire for Eating Disorders (SOCQ-ED), the Pros and Cons of Eating Disorders Scale (P-CED), the Self-Efficacy Scale (SES), and the Rosenberg Self-Esteem Scale (RSES). A total of 125 participants completed the assessment post-treatment. Completer analyses and intent-to-treat analyses were performed.

RESULTS

Significant time × group interactions were found, indicating a stronger increase in motivational aspects and self-esteem, in addition to a stronger symptom reduction on some measures from pre- to post-treatment in the intervention group compared to the control group.

CONCLUSIONS

Internet-based approaches can be considered as useful for enhancing motivation to change in eating disorders and for yielding initial symptomatic improvement.

Content analysis of male participation in pro-eating disorder web sites

The pro-anorexia community has emerged as a powerful cultural movement that takes an at least partially positive attitude toward anorexia nervosa and other eating disorders. A systematic review of the literature on pro-ana forums focused specifically on females with eating disorders. However, epidemiological data suggest that as much as 25% of the eating disorders population is male. In our review of pro-anorexia web sites, we found a substantial number of participants were male. We conducted a qualitative content analysis of male participation in pro-ana forums in an effort to learn more about male participation in these forums. In this article, we present the results of this analysis, highlighting themes of social support, community appreciation, and ambivalence, as well as themes that appear to be particular to the male experience of eating disorders, such as alienation and teasing.

Eating disorders in collegiate female athletes: factors that assist recovery

The purpose of this study was to identify factors that assist female athletes' recovery from eating disorders. Forty-seven female collegiate athletes who experienced eating disorders responded to an open-ended question regarding factors that most helped their recovery. The most common factors were the desire to be healthy enough to perform in sport, support from others, and shifts in values/beliefs. A unique finding was that the desire to be healthy enough to perform in sport most frequently facilitated recovery. This knowledge can help treatment providers to foster athletes' motivation to recover and distinguishes athletes as a unique treatment population from non-athletes.

Assessing motivation to change in eating disorders: a systematic review

BACKGROUND

Patients with anorexia and bulimia nervosa are often ambivalent about their eating disorder symptoms. Therefore, a lack of motivation to change is a frequent problem in the treatment of eating disorders. This is of high relevance, as a low motivation to change is a predictor of an unfavourable treatment outcome and high treatment dropout rates. In order to quantify the degree of motivation to change, valid and reliable instruments are required in research and practice. The transtheoretical model of behaviour change (TTM) offers a framework for these measurements.

OBJECTIVE

This paper reviews existing instruments assessing motivation to change in eating disorders.

METHOD

We screened N = 119 studies from the databases Medline and Psycinfo found by combinations of the search keywords 'eating disorder', 'anorexia nervosa', 'bulimia nervosa', 'motivation', 'readiness to change', 'assessment', 'measurement', and 'questionnaire'.

RESULTS

Ultimately, n = 15 studies investigating psychometric properties of different assessment tools of motivation to change in eating disorders were identified. Reviewed instruments can be divided into those assessing the stages of change according to the TTM (6 instruments) and those capturing decisional balance (3 instruments). Overall, the psychometric properties of these instruments are satisfactory to good.

DISCUSSION

Advantages, disadvantages, and limitations of the reviewed assessment tools are discussed. So far, the TTM provides the only framework to assess motivation to change in eating disorders.

Figured World of Eating Disorders: Occupations of Illness

Background. The biomedical diagnosis of eating disorders signifies a mental illness with complex physical symptomology. The socio-cultural determinants and impact of eating disorders on daily occupations are not adequately addressed in this classification.

Purpose. This paper introduces the concept of a figured world as a framework for how eating disorders exist in daily activity and social discourse. How occupations become ascribed with meaning generated by an eating disorder will be proposed through the voice of a composite character in the figured world.

Key Issues. Central elements to contextualizing figured worlds include positional identity, self-authoring, and semiotic mediation. The generation of meaning in illness arises from the integration of these elements into this specific figured world.

Implications. The competing agendas of the biomedical model and figured world permit a new understanding of the challenges associated with recovery. For occupational therapists, these challenges require the reattribution of meaning of daily occupations.

The myths of motivation: time for a fresh look at some received wisdom in the eating disorders?

The eating disorders typically involve poor motivation to change. This article reviews the evidence behind many of our beliefs about motivation and whether we need a different conceptual framework for understanding why patients commonly get "stuck." The outcome literature is reviewed, and demonstrates that there is little evidence that we are effective in enhancing motivation to induce changes in symptoms. Indeed, there are suggestions that commonly used models are unhelpful. Verbal expressions of motivation are not the best indicator of likely treatment response, and can best be understood as providing a "manifesto," which has functions that can obstruct recovery from the eating disorder. A behavioral analysis of motivation is likely to be more effective. Cognitive, emotional, and behavioral methods for enhancing motivation are outlined, with the aim of bypassing the motivational manifesto and encouraging positive therapeutic change.

The efficacy of a brief motivational intervention for individuals with eating disorders: a randomized control trial

OBJECTIVE

Individuals with eating disorders are often ambivalent about recovery, and previous research has shown that readiness for change predicts enrollment in intensive treatment, symptom change, dropout, and relapse. Given the demonstrated importance of readiness for change, researchers and clinicians have turned to investigating interventions designed to enhance motivation. The purpose of this research was to determine the efficacy of Readiness and Motivation Therapy (RMT), a five-session individual preparatory intervention for individuals with eating disorders.

METHOD

Participants completed the Readiness and Motivation Interview and measures of eating disorder symptomatology, self-esteem, and psychiatric symptoms at intake. One hundred eighty-one participants were randomly assigned to the treatment (RMT) or wait-list control condition and were reassessed at 6-week and 3-month follow-up; 113 completed assessments at all three time points and primary analyses were based on these individuals.

RESULTS

Surprisingly, improvements in readiness for change, depression, drive for thinness, and bulimia symptoms occurred over time in both RMT and control conditions. However, at post and at follow-up, individuals who received RMT were less likely to have high ambivalence than were those from the control condition.

DISCUSSION

RMT may be of benefit to highly reluctant, clinically challenging patients and help them make better use of future, action-oriented treatment.

Eating disorders and psychoeducation--patients' experiences of healing processes

In the treatment of eating disorders, little is known about the role and impact of psychoeducative programmes and whether patients experience such programmes as helpful in their healing processes. Examining these questions is the purpose of this study, using an explorative and descriptive design based on content analysis. Thirteen female patients participated in qualitative interviews. The analysis of healing processes experienced during the programme participation resulted in six main categories, i.e. 'Self-awareness', 'Setting boundaries', 'Feelings and self-mobilization', 'Self-regulation', 'Self-reflexivity' and 'Motivation and Self-improvement'. Our study clearly indicates that according to the patients' experiences, a psychoeducative programme may facilitate healing processes. The study also supports a possible indirect impact on healing processes in terms of more readiness to seek treatment. There is a need for more knowledge about how to bring about an effective interplay between treatment and psychoeducative programmes.

Motivation to change among residential treatment patients with an eating disorder: assessment of the multidimensionality of motivation and its relation to treatment outcome

OBJECTIVE

To examine the multidimensional nature of motivation to change in an adolescent sample in residential eating disorder (ED) treatment and relate it to outcome.

METHOD

To determine whether different dimensions of motivation (benefits, burdens, and functional avoidance) are differentially associated with symptom severity and outcome, we assessed eating pathology and motivation to change in consecutively admitted female patients (n = 67) with AN, BN, and EDNOS in a residential ED program with the Eating Disorder Examination Questionnaire (EDE-Q) and the Decisional Balance Scale (DB).

RESULTS

Pretreatment DB benefits and functional avoidance subscales were correlated with ED and comorbid psychopathology. Admission to discharge change in DB benefits-but not other measured dimensions of motivation was significantly associated with post-treatment EDE-Q global scores.

DISCUSSION

Our findings support that motivation to change is a multidimensional construct among ED patients. A reduction in perceived benefits of illness is associated with less severe post-treatment eating pathology.

The concept of body image disturbance in anorexia nervosa: an empirical inquiry utilizing patients' subjective experiences

We explored the concept body image disturbance (BID) by utilizing the subjective experience of 32 women (aged 20-39 years) diagnosed with AN (DSM-V). Using methods from Grounded Theory we identified four phenotypes of BID-"Integration," "Denial," "Dissociation," and "Delusion"-which differed according to whether the patients overestimated their own body size ("Subjective reality"), and whether they acknowledged the objective truth that they were underweight ("Objective reality"). The results suggest that BID should be conceptualized as a dynamic failure to integrate subjective experiences of one's own body appearance with an objective appraisal of the body. Conceptual, diagnostic and clinical implications are discussed.

Reluctance to recover in anorexia nervosa

OBJECTIVE

Reluctance to recover may explain poor treatment outcome and high dropout and relapse rates in the treatment of anorexia nervosa (AN). This study systematically explored what AN patients describe as interfering with their wish to recover.

METHOD

Two independent samples of women with AN (total N = 36) were interviewed in-depth using a phenomenological study design. Interviews were tape recorded, transcribed and analysed using QSR-NVivo7 (QSR International, Melbourne, Australia) software.

RESULTS

Seven core obstacles were found to interfere with informants' wish to recover as follows: (i) 'perceiving judgements'; (ii) 'feeling stuck'; (iii) 'feeling distressed'; (iv) 'denying AN'; (v) 'eating'; (vi) 'gaining weight'; and (vii) 'appreciating the benefits'.

CONCLUSION

The wish to recover is an autonomously based, fundamental motivational requirement for becoming ready to change. Understanding factors that contribute to this wish adds to the clinician's toolbox in motivational work with AN patients.

Illness perception and its relationship to readiness to change in the eating disorders: A preliminary investigation

OBJECTIVE

This study investigated the psychometric properties of a modified version of the Illness Perception Questionnaire - Revised (IPQ-R) in individuals with eating disorders. The relationship between illness representations and stage of change was then explored. Design and method. A cross-sectional design was employed and participants were asked to complete a set of questionnaires. A subset of participants completed the IPQ-R again after 2 weeks in order to assess test-retest reliability. The relationship between illness representations and stage of change was explored using hierarchical multiple regression analyses.

RESULTS

Sixty-nine participants with a clinical eating disorder took part in the study. With the exception of the causal subscales, the modified version of the IPQ-R had good internal validity and good test-retest reliability. Consequences, treatment control and personal control as well as cyclical timeline perceptions accounted for a significant and unique amount of variance in readiness to change stage scores.

CONCLUSIONS

Findings suggest that this modified version of the IPQ-R provides a reliable means of exploring illness representations in individuals with eating disorders. Given the significant relationships between illness representations and stage of change, it may be helpful to consider these aspects of illness representations when carrying out therapeutic work with this clinical population. Further research might usefully investigate the relationship between illness perceptions and clinical outcome, as well as examine what factors are important in the shift between stages of change in a longitudinal design.

Anorexia nervosa: Valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice

Anorexia nervosa (AN) is highly valued by people with the disorder. It is also a highly visible disorder, evoking intense emotional responses from others, particularly those closest to the person. A maintenance model of restricting anorexia nervosa, combining intra- and interpersonal factors is proposed. Four main maintaining factors (perfectionism/cognitive rigidity, experiential avoidance, pro-anorectic beliefs, response of close others) are suggested and the evidence supporting these is examined. These factors need to be integrated with what is known about starvation-related maintenance factors. This model departs from other models of AN in that it does not emphasize the role of weight and shape-related factors in the maintenance of AN; that is, it is culture-free. Implications for clinical practice and research are discussed.

Expanding the concept of motivation to change: the content of patients' wish to recover from anorexia nervosa

OBJECTIVE

Motivational approaches to anorexia nervosa (AN) have mainly concerned motivational quality and quantity. We investigated the content of patients' wish to recover.

METHOD

Eighteen women, aged 18-39, with AN were interviewed in depth using a phenomenological study design. Interviews were tape-recorded, transcribed, and analyzed using the QSR-N*Vivo software program.

RESULTS

Four motivational content areas characterized informants' wishes to recover: "Sense of vitality" (e.g., joy, concentration, spontaneity, energy); "Sense of autonomy" (e.g., choosing to recover, new methods of mastery, self-determination); "Sense of insight" (e.g., awareness, seeing nuances, limitation of goals, self-knowledge); and "Negative consequences" (e.g., loss of future, costs to own children, feeling sick or thin, social costs, physical costs).

CONCLUSION

Our sample of AN patients' motivation to recover may be described using three dimensions: content, quality, and quantity, and may also include motives with no behavioral intention. Sustained therapeutic success may rest upon the therapist's ability to identify and ally with the patient's motives to recover.

Stages of change in anorexic and bulimic disorders: the importance of illness representations

This study investigated the relationship between illness representations and stage of change in women with anorexic (N=33) and women with bulimic (N=36) disorders. A cross-sectional design was employed and participants were asked to complete a set of questionnaires. The relationship between illness representations and stage of change was explored in the two groups separately using hierarchical multiple regression analyses. A number of different items from the illness representations measure, together with locus of control and social support, explained relatively high proportions of the variance in each stage of change in the two groups. Where similar items emerged as important in both groups, their relative importance showed variation according to stage of change being considered. Implications for differential approach to treatment in the two disorders are discussed in the context of the study limitations.

Treatment perception in adolescent onset anorexia nervosa: retrospective views of patients and parents

OBJECTIVE

To investigate perception of treatment in former patients with anorexia nervosa (AN) and their parents, and to determine whether this was related to outcome and treatment characteristics. Client satisfaction is important for treatment engagement and adherence.

METHOD

Forty-six (of 55) girls with adolescent onset AN, 33 mothers and 26 fathers participated in a follow-up study conducted 8.8 (SD 3.3) years after start of treatment. The former patients were assessed using diagnostic interviews. Only nine participants (19%) had an eating disorder (ED) at follow-up. Perception of treatment was assessed by questionnaires.

RESULTS

Parents reported having an overall positive perception of treatment. However, reports from former patients were significantly more negative than from the parents. In former patients, the "perception of therapists" total score and the items "therapists' knowledge of ED" and "usefulness of pediatric inpatient treatment" correlated with ED symptoms at follow-up. The perception of therapists' scores of the parents were not associated with the ED outcome of their daughters. More family therapy sessions were associated with the former patients' satisfaction with the therapists, while higher age at admission was associated with their mothers' satisfaction.

CONCLUSION

In spite of good ED outcome, former patients were only moderately satisfied with their treatment, whereas parental satisfaction was high.