# Motivation and emotion/Book/2014/Eating disorder recovery and motivation

* Multimedia presentation (5 min)

## Overview

Imagine hating yourself. Imagine feeling so uncomfortable in your own skin that you would do almost anything to get out of it. Imagine feeling completely alone and consumed by fear. These are just some of the feelings those suffering from eating disorders may feel.
Eating disorders (EDs) are a major problem within today's society. According to the National Eating Disorder Collaboration (2014), in regards to mental illnesses, EDs are the twelth leading cause of hospitalisation in Australia. More specifically, for Australian females aged 15 to 24 years, bulimia nervosa (BN) and anorexia nervosa (AN) are the eighth and tenth biggest burden of disease and injury (NEDC, 2014).
These statistics demonstrate the important of research in to all aspects of EDs including cause, treatment and recovery. This chapter will focus on how motivation can effect recovery from an ED and ways that therapeutic techniques have incorporated motivational aspects into the process of ED treatment.
Not only does motivation have an impact on a sufferer's likelihood of reaching out for help in the first place, their motivation levels throughout the treatment process also impacts greatly on recovery outcomes.

## Learning objectives

* To define eating disorders.
* To define motivation.
* Establish the link between eating disorder recovery and motivation.
* Establish the theories behind eating disorder recovery and motivation.
* Understand current practices to increase motivation within the eating disorder population.

## What is motivation?

According to Reeve (2009), motivation is focused around two questions: (1) what causes behaviour; and (2) why does behaviour vary in intensity? In studying and examining motivation, these two questions are kept in mind. Motivation is believed to come from two main sources; (1) internal motives; and (2) external events. From internal motives stems three further sources; needs, cognitions and emotions (Reeve, 2009). The way motivation is expressed can be seen in four ways: behaviour, engagement, brain activation and physiology, and self-report (Reeve, 2009).
Table 1. Motivational Aspects (adapted from Reeve, 2009).
| Motivation expression | Description |
| Behaviour | Attention, latency, effort, persistence, choice, probability of response facial expressions, bodily gestures. |
| Engagement | Emotional, cognitive and voice. |
| Brain activation and Physiology | Central nervous system and hormone systems. |
| Self-report | Motivational states. |

## What are eating disorders?

EDs can be characterised by severe disturbances in both body image and eating behaviors (Makino, Tsuboi & Dennerstein, 2004). The most common forms of EDs are AN, BN, other specified feeding and eating disorders (OSFED) and binge eating disorder (BED). Regardless of the specific type of ED, all can result in distress, impairment in functioning, depression and mortality (Stice, South, & Shaw, 2012). There has been research conducted that has found that 46% of individuals diagnosed with AN make a full recovery, while 20% remain ill for the long term[factual?]. The same research has also found that BED is more common in the Australian population then AN and BN (NEDC, 2014). According to Stice et al. (2012), individual EDs can be described in the following way:
* Anorexia Nervosa (AN):
* Excessive exercise and excessive caloric restriction.
* Extreme fear of becoming fat.
* Disturbances in self-evaluation related to body weight/shape or disturbed perception of one’s body weight/shape.
* Denial of low weight.
* Amenorrhea (for females).
* Bulimia Nervosa (BN):
* Consumption of excessive amount of calories in a small amount of time, accompanied by feelings of loss of control and guilt.
* Disturbances in self-evaluation related to body weight/shape or disturbed perception of one’s body weight/shape.
* Unhealthy behaviors to prevent weight gain (such as purging or laxative abuse).
* Other Specified Feeding and Eating Disorders (OSFED):
* This form of ED often comes with much debate. It used to be known as eating disorder not otherwise specified and describes those disorders that do not fit all the criteria of AN or BN (Machado, Gonvcalves, & Hoek, 2012). For example, according to the DSM-IV-TR[explain?], females who have all AN symptoms but still menstruate would fit the OSFED diagnosis. Similarly, if one fits all the AN symptoms but remain in a normal weight range, they too would fall within the OSFED diagnosis.
* Binge Eating Disorder (BED):
* BED was first introduced in 1994 in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (Striegel-Moore & Franko, 2003). It is often associated with very high obesity rates and psychiatric comorbidity Striegel-Moore & Franko, 2003). It can be characterised by periods of excessive caloric consumption followed by feelings of shame and guilt (Striegel-Moore & Franko, 2003).
There has been extensive research conducted about the etiology of EDs and evidence has shown that both biological and cultural factors interact with environmental factors to influence the incidence of an ED occurring (Striegel-Moore & Bulik, 2007; Stice, South & Shaw, 2012). Research has also found that despite EDs being historically a Western, industrialised societal problem affecting mostly Caucasian females (Smink, von Hocken & Hoek, 2012), a rise in the prevalence of the illnesses among non-Western countries like Japan and the Middle East is occurring at a steady rate (Makino et al., 2004). This rise may be due to the increased societal pressures through globalisation and exposure to Western media (Makino et al., 2004).

## Theoretical frameworks
### The transtheoretical model of change

The transtheoretical model of change (TMC) was first put forward by Prochaska and DiClemente in 1984. The central focus of this model is based on stages of change, which is believed to correlate with the process of change a person is most likely to go through when moving towards problem solving (Levy, 1997). The model consists of five identified stages of change:
* Pre-contemplation: Those people in this initial stage may not be aware there is a problem and therefore do not intend on changing the problem behavior. If they do happen to be aware of a problem, they are unwilling to make the required changes (Levy, 1997).
* Contemplation: Within this stage, people consider and intend to make changes to their behavior, usually within the following six months. During this time, people become aware of the problem and thus they make active attempts to consider change, however they are not yet ready to make active behavior changes (Levy, 1997).
* Preparation: During this preparation stage, people intend to make behavior changes, which usually are planned to occur in the following month (Levy, 1997).
* Action: This is the stage where behavior change actually occurs and often is considered the busiest stage that requires commitment, time and energy (Levy, 1997).
* Maintenance: During this final stage, relapse prevention is the primary focus. This stage can often produce challenges and people often fall back to the action stage (Levy, 1997).
A secondary focus of the TMC is the notion of change processes (Levy, 1997). The processes of change were determined through analysis of different change techniques and theories and include the processes outlined in Table 2. The processes of change are what individuals experience during the different stages of change (Levy, 1997).
Table 2. Processes of Change (adapted from Levy, 1997).
| Process | Name | Example |
| 1 | Consciousness raising | Increasing information about oneself and the problem. |
| 2 | Self-liberation | Belief in one's ability to change behaviour. |
| 3 | Dramatic relief | Experiencing and expressing feelings about the problem and solutions. |
| 4 | Counter conditioning | Implementing alternatives for the problem behaviour. |
| 5 | Stimulus control | Avoidance of behaviour eliciting stimuli. |
| 6 | Helping relationships | Sharing about the problem with caring people. |
| 7 | Environmental re-evaluation | Assessment of the problems effects on the environment. |
| 8 | Social liberation | Increasing alternatives available in society. |
| 9 | Self-re-evaluation | Assessing how the problem is viewed by oneself. |
| 10 | Reinforcement management | Rewards for making changes. |
An example of how the TMC has been used in relation to EDs is demonstrated in the case study outlined below.
Case study
A study of 139 participants (with a mean age of 29 years), examined BN behaviors and their relationship with the processes and stages of change as identified in the TMC[factual?]. Half the subjects were recruited from treatment settings, while the other half were from non-treatment settings such as health clubs, university nutrition classes, athletic teams and university residences. Subjects were required to complete various questionnaires and were divided into one of five treatment groups. The groups were as follows:
Table 3. Description of Treatment Groups[explain?] (adapted from Levy (1997).
GroupTreatment Description
A. Least ActiveParticipants meet to provide informal support and read informative information about binge-purging if they chose.
B. ExplorationParticipants are able to explore their relationship with food if they choose to.
C. Goal-SettingParticipants have the opportunity to learn to form goals in relation to the behaviour change they are aiming for. Support and help provided.
D. SkillsParticipants meet to learn ways to change their behaviours with support and help around pitfalls and barriers also provided.
E. Relapse PreventionParticipants learn how to maintain changes they've made.
Results found that the stage of change and processes of change in BN had a significant relationship. The data demonstrated that those with BN significantly preferred treatment processes that took into account the level and readiness of change the individual was at. Those participants in groups C to E had more improvements than those in groups A and B. :

### Self-Determination Theory

Another theory that has been accepted and utilised in the treatment of EDs is the Self-Determination Theory. This theory divides motivation up into different parts that can be placed on a continuum of self-determination.
At the start of the continuum is amotivation (i.e. without motivation). At this stage, the person has no motivation at all. Within the middle of the continuum, extrinsic motivations are divided into four aspects, which are dependent on their degree of autonomy. Finally, the end of the continuum accounts for the intrinsic motivations that resemble autonomy (Geller, Zaitsoff & Srikameswaran, 2005). In relation to EDs, within this framework when autonomy is felt by an individual in association with treatment, the person is then better able to engage in the change (Darcy et al., 2010).
Vandereycken and Vansteenkiske (2009) found evidence to support the theory by comparing two groups of patients being treated for BN. The groups were treating in either a standard manner or were engaged with a procedure that aimed to increase autonomy and personal responsibility (Vandereycken & Vansteenkiske, 2009). Results showed that the patients in the second group had greater motivation to remain in treatment and change the required behaviours (Vandereycken & Vansteenkiske, 2009).

## What is the link between motivation and eating disorder recovery?

Those suffering from EDs are commonly described as having ambivalent feelings towards change (i.e., recovery) (Geller & Drab, 1999; Nordbe et al., 2008). This ambivalence may result in challenges to their motivational view about recovery. This reluctance to recover (and thus, give up eating disorder symptoms and behaviors) can be seen as an avoidance and safety strategy (Petterson, Thune-Larsen, Wynn, & Rosenvinge, 2013). For those with an ED, the negative behaviors and symptoms develop into negative reinforcers, which serve as a blocking technique against recovery challenges (Petterson et al., 2013) such as fear of loss of control, insecurities and uncertainties (Leung, Ma, & Russell, 2013).
According to Leung et al. (2013), a fundamental step in recovery is having motivation to change and enhancement in motivation results in positive treatment outcomes. An example of this association between motivation and treatment outcomes was demonstrated in a study conducted with 125 BN patients[factual?]. The study examined treatment and symptom reduction following four weeks of motivational enhancement therapy (MET) and four weeks of cognitive behavioral therapy (CBT). Results found that the MET produced the same symptom reduction results as the CBT, as well as increasing motivational change (Leung et al., 2013). Similarly, a study by Treasure et al. (as cited in Jones, Bamford, Ford, & Schreiber-Kounine, 2007) found that motivation had an impact on a global level (program participation) and on a symptomatic level (symptom reduction).

## Current strategies to improve motivation in eating disorder patients

Because of the evidence that shows those suffering from EDs are often resistant to change, motivational issues are becoming more embedded within the treatment process (Geller, Brown, & Srikameswaran, 2011). One form of treatment incorporating motivation is the use of motivational interviewing (MI).
MI is an approach that stems from the transtheoretical model and aims to help people to work through their hesitations to change (Wade, Frayne, Edwards, Robertson, & Gilchrist, 2009). It was originally used in the treatment of substance abuse but has also been used in other problem areas such as obsessive compulsive disorder, suicidality and gambling addiction (Geller et al., 2011). More specifically for EDs, MI is focused around helping the individual to first recognise their illness, and then aid them in reaching a point were they are ready to change the problem behaviors (Geller et al., 2011).
The process of MI is client-centred, with the therapist there to explore and resolve any ambivalance about recovery (Geller et al., 2011). An assessment tool used during the MI process is the Readiness and Motivation Interview (RMI). This tool is a semi-structured interview that is designed to assess the motivational level of the client by providing readiness and internality scores in relation to symptoms of EDs (dietary restriction, cognitive symptoms, bingeing and compensatory behaviors) (Geller, Brown, Srikameswaran, Piper, & Dunn, 2013). It utilizes knowledge based on the different phases of change; pre-contemplation (not wanting to change), contemplation (thinking about changing), and action (active participation in change) (Geller et al., 2011). Research has shown that the scores formed through the RMI can predict participation and drop out of treatment, change in symptomatic behavior and relapse (Geller et al., 2013).

## Conclusion

As stated within this chapter, EDs are a serious and dangerous mental illness. The prevalence of them are increasing throughout societies around the world, and result in various individual and societal costs. For this reason, it is essential that further research into all aspects of EDs is undertaken. More specifically in relation to motivation and eating disorder recovery, the NEDC (2014) suggest the following steps to help someone recover:
* Support – A sense of support will help the treatment process and decrease the sense of loneliness and isolation a sufferer may feel.
* Hope and motivation – Maintain motivation and a sense of hope will aid in the recovery process.
* Healthy self-esteem – Reminding the individual that they are worth more than the disorder.
* Understanding and expressing your emotions – It is normal for a person with an eating disorder to feel a range of emotions and it is helpful to acknowledge and express feelings in a safe and supportive environment.
* Acknowledging set-backs – With the focus on recovery, even taking a step backwards can still be making progress - just like an arrow, sometimes you need to go back in order to move forward.
* Coping strategies – Having a strong list of strategies to use in time of difficulty can help the individual stay on track and maintain motivation for recovery.
* Engaging in activities and interests –Provides the individual with enjoyable and healthy activities.
As the research demonstrated throughout this chapter has found, it is important that therapeutic processes take into account motivation levels and barriers of the individuals in order for the best possible treatment outcomes.