Objective
Although eating disorders cause severe somatic and psychological sequelae, a majority of affected patients are not motivated for treatment. The aim of this study was to assess stages of change in patients with eating disorders and to analyze their correlations with clinical characteristics and treatment processes using Prochaska's transtheoretical model of change.
Methods
A consecutive sample (N=88) including outpatients suffering from anorexia (n=29), bulimia (n=32), and eating disorders not otherwise specified (n=27) was recruited from an eating disorders clinic with a low-threshold access. The patients' readiness to change their eating behavior was assessed by a self-rating scale (URICA), and a score for each participant on each subscale (precontemplation, contemplation, action) was derived from the scale. Patients were introduced to a set of eight treatment processes over the course of four treatment sessions. During the four sessions, therapists rated whether or not patients appeared to be using each of the treatment processes.
Results
While diagnostic subtype, age, illness duration, and previous treatments were not associated with motivational stages, self-referral was positively correlated to treatment motivation. Emotional involvement, specific behavioral change processes, and beginning a continuing treatment were correlated with more advanced stages of change.
Conclusion
This study supports the notion of the stages of change as an independent dimension that is relevant for the treatment of eating disorders. The lack of impact of previous, presumably nonspecific treatments on the stages of change underlines the importance to assess and to improve specifically patients' motivation. Therapeutic work towards the mobilisation of emotions with regard to their eating problem as a means to improve readiness to change should be examined in future studies.
One of the most striking phenomena in patients with eating disorders is their lack of motivation for treatment. Even when confronted with the potentially severe sequelae of their disturbed eating behavior such as retardation of emotional development or osteoporosis, a majority do not show cognitive insight or emotional reactions concerning their physical and psychological health [1]. The impact of this lack of motivation is serious: it is estimated, for example, that over 90% of bulimic subjects are not under adequate treatment [2], whereas anorexic patients were found to be even less motivated and more often referred by others for treatment than patients with nonanorexic types of eating disorders [3]. Motivation for treatment appears to shift over the course of illness, increasing with age, illness' duration and years of treatment [3]. Although there is a convergence of recommendations for enhancing motivation in the scientific literature including psychoeducation, examination of advantages and disadvantages and exploration of personal values [3], only a few attempts have been made to evaluate those strategies [4] and [5]. Prochaska's transtheoretical model of change [6] was proposed as one of the most promising theoretical frameworks to develop and test specific techniques aimed at enhancing motivation for change [7].
The transtheoretical model of change [6] is a higher order theory of psychotherapy and recognizes that people do not make a black or white decision to change their behavior. It rather holds that behavior change is a gradual process, divided into phases. These are termed the “stages” of change or “the when to change”. The “processes” of change or the “how to change”, are the overt and covert activities an individual engages in to modify thinking, behavior or affect in relation to a problem. Finally, the “level” of change or the “what to change” describes the kind of psychological problems that are targeted by the processes of change comprising symptoms, maladaptive cognitions, interpersonal and intrapersonal conflicts.
The transtheoretical model has been successfully applied to a variety of health behaviors such as smoking cessation [8], panic disorder [9], weight control [10], fat intake [11], and exercise acquisition [12]. While the concept of the stages of change applies to a variety of health behaviors, no single trajectory of change processes was observed for all health behaviors, and, therefore, process–stage relationships should be examined for each health problem separately [13].
Patients with eating disorders show different levels of motivation to change different aspects of the eating disorder. They may be highly motivated to stop binge eating but not at all prepared to consider changing their strict dieting behavior; this complicates the application of the transtheoretical model of change to eating disorders and the measurement of readiness to change of eating disorders [4], [14] and [15]. Furthermore, the treatment may modify stage–process relationships: a randomised controlled trial on treatment of cognitive–behavioral (CBT) versus interpersonal therapy (IPT) for patients with bulimia nervosa found stage of change as a predictor of the response to IPT, but not to CBT, possibly due to motivation enhancement through directly addressing eating disorder symptoms across the 19 CBT sessions [16]. Interestingly, stage of change did not predict dropout.
The aim of this study was to test whether scores on the various stages of change correlate with use of specific processes of change (e.g., self-reevaluation, feedback, stimulus control) in patients with eating disorders treated in a psychiatric primary care setting. Because treatment has been found to influence the use of change processes [16], we assessed change processes observed under a defined treatment condition. We hypothesized that (1) advanced stages of change would be positively associated with bulimic symptoms, patients' age, illness duration, previous treatment experiences and self-referral to treatment, and (2) the stages of change would be associated with specific processes of change as predicted by Prochaska et al. [17].
