Lecture 22 - Motivational interviewing added to Family Based Treatment for Adolescent Anorexia

Question 1

Anorexia Nervosa

Answer 1

Motivational interviewing important.
Video on anorexia
Kind of doctor or therapist we’d hope to be able to meet if we had problems or our family
-empathetic, clear minded, scientific

1 of 4 forms of eating disorder
1% prevalence
Primarily occurs in adolescence
Highly resistant to change
-Often lack of motivation/desire to recover
-Feel like doing well, that nothing wrong, everybody else is wrong
 Ego-syntonic (no distress)

Key Features:
 Dramatic weight loss
 Intense fear of gaining weight
 Body image distortion
 Additional Features:
 Anxiety concerns
 Obsessive-compulsive style

Heart attack risk

Question 2

Motivational Issues to Consider

Answer 2

Ambivalence and resistance
Autonomy and control
Introjection and compulsions
- Important to Externalize the disorder
– Ed or Edie
– The anorexic voice
 Structure and Autonomy Support
-Scaffolding: Structures to
promote growth and stability

Question 3

The Maudsley approach (Family-Based Treatment)

Answer 3

Help parents help their kids
No blame
Illness seen as separate

Parents best agent to help

3 stages:
 Return to previous weight.
 Gradual return to adolescent
control of eating.
-Returning independence
 Gradual exploration of Autonomy
and Identity issues
-Reengaging in life

Change Mechanism?
 Exposure
 Decreasing ambivalence (seeing positive sides about gaining weight)
 Increasing autonomy

Mean age around 11-12…
11-12 year olds easier to treat because
not so good at hiding, secret
Also smaller so more taken care of by the parent

Question 4

The Problem with FBT

Answer 4

FBT is very successful at stage 1.
-Immediate goal: make sure doesn’t die
-Take out of danger zone
- Accounts for empirically validated success.
Many patients (and families) have difficulty with the
transition to independent eating.
–problem: when at school, won’t actually eat…
-Maintenance of cognitive symptoms (ex: Still some phobia about gaining weight)
-Maintenance of safety behaviors (ex: Exercising a lot to keep weight down)
Possible Solution:
- Add treatment elements that promote motivation to change.

Question 5

Motivational interviewing applied to fam-based tx of Anorexia

Answer 5

Janet Treasure… thought motivational interviewing could help with that
Explore autonomy and identity
-J.T. Believes should be dealt at the same time ad previous stage or earlier

Motivational interviewing
Integrated with family-based treatment
Thought to facilitate the motivation to change.

Question 6

Motivational Interviewing (MI)

Answer 6

 Founders: Dr. William Miller & Dr. Stephen Rollnick (1991)
 “Patient-centered, directive counseling style that builds on
intrinsic motivation to facilitate change in health-related
behaviours”

Series of open questions

Help with ambivalence

Identity where the individual is in the stages of change

Stages of change:
-Precontemplation: awareness of need to change, self-reflection (goal: increase awareness)
-Contemplation: struggle with pros and cons (goal: motivate and increase confidence in ability to change)
-Preparation: negotiate implementation plan
Action: do it and learn from mistakes (goal: reaffirm commitment and follow up)
Maintenance: review and prevent relapse (goal: encourage active problem solving)
-if relapse, assist in coping

A lot of teens at precontemplation stage (increase awareness of need to change, self-reflection)

Discrepancy

Some examples of motivational components
The Readiness Ruler
 Measuring Readiness to Change
Not interested Eager to put change
in change in place
0—1–2–3–4–5–6–7–8–9—10
Can be adapted to various symptoms
of the eating disorder

Importance and confidence are the
drivers of change.

Every week make sure patient still committed to plan, confident can do it and whether some resistance

Personalize the ED (separate being)

Open ended questions, but kind of an idea where going

Home hospitalization for younger teens (less traumatizing)

Question 7

Motivational Interviewing (MI): Pros

Answer 7

What are the advantages?
 Compatible with individual differences in ambivalence
 Suitable for mandated treatments
 Brief
 Trainable
 Non-confrontational

Question 8

Motivational Interviewing (MI): “Lingo”

Answer 8

4 principles:
 Expressing empathy
 Developing discrepancy
-Pros and cons
-Listening if something positive and growth oriented
 Rolling with resistance
 Supporting self-efficacy
-Wow, you’re going out with your friends to eat

Change self-talk

4 Techniques: OARS
 OARS:
◦ Open-ended questions
◦ Affirmations
◦ Reflective listening
-Reflect back the things that are most likely to lead to change, growth
◦ Summaries
-3 times during session
-Stop and review and highlight
-So patient can think about and maybe internalize

Question 9

Motivational Interviewing (MI): Goals

Answer 9

 Develop discrepancy between current behaviour and values
 Decrease ambivalence
 Let clients decide on their own to change
 Enhance readiness to change
“A method of communication rather than a set of techniques”

Question 10

MI: Does it work?

Answer 10

Meta-analyses of 72 studies:
 works in small doses; has relatively large effects
 Efficacy is enhanced by negativity; works better with angry,
resistant people; works by reducing negativity!
 Therapists differ in their efficacy in using motivational
interviewing; empathy is the best predictor of therapist
success

MI & Adolescents
Why would it work with adolescents?
1. Supports role development
2. Non-confrontational
3. Promotes autonomy
4. Deals with ambivalence

Question 11

MI & Adol. Health Behaviour Change

Answer 11

Meta-analysis: motivational interviewing and adolescents
 The use of MI is increasing for adolescents
 Primarily evaluated for adolescent substance use
 Expanding to other health behaviors

 25 studies examined substance use
D = .20
 14 marijuana use
 12 alcohol use
 11 tobacco use
 5 street drugs

 10 studies examined non-substance use behavior
D = .35
 4 diet and physical activity
 3 diabetes management
 3 sexual risk behavior

Long term follow-ups show
gains are maintained

Prof’s story of covid vaccine and black people’s distrust

Motivational interviewing helped

Motivational interviewing = Adjunct to other treatments for teens

Promotes sense of readiness for change

Question 12

Conclusions

Answer 12

Motivational interviewing acknowledges the
resistance and ambivalence most people have about
changing their behavior.
Motivational interview may help anorexic teens in
family-based treatment move toward change.