Introduction What This Book Is and How To Use It What This Book Is NOT and How NOT To Use It Psychology and the Media: undoing the notion of a "quack" A Word About Motivation and Readiness

Readiness and Treatment for Eating Disorders

Motivation determines successful treatment for eating disorders

For those suffering with eating disorders, controlling the impulse to overeat may be as hard as controlling the impulse to abstain from using drugs or alcohol. All addictions involve behaviors that override logic and reasoning. Abusing any substance can be deadly, yet the user typically remains unmotivated for treatment. "Readiness" to change is a construct that is often researched by psychologists. Obviously, it makes sense that the more "ready" and "motivated" a person is to change, the more successful and rapid eating disorder treatment for their eating disorder may be.

Conversely, it would then follow that if a person is "unmotivated" or "not ready" to change, that treatment attempts would not be fruitful. This, however, is not necessarily true. In working with eating-disordered patients I encounter this reluctance quite frequently. For example, a parent may bring their daughter to treatment for fear that she may eventually become anorexic. The parents see her continuing to lose weight and she repeatedly comments on feeling fat, despite wearing a size 2. If her parents wait until she is "ready," she will be thinner and may be medically compromised. Even on their deathbeds, some anorexics are not ready to get better and some remain in denial that they have anorexia at all. Denial and resistance about any illness can be harmful or even deadly, but it can be a focus of treatment in and of itself.

Outcome research clearly states that delaying treatment for eating disorders is the one treatment variable that best predicts poor outcomes such as in-patient stays or treatment failure. Denial grows as time goes on, making it tougher and tougher to break (Yanovski, 2003). The treatment goal for our pre-anorexic teen would be to break through her denial about her illness. Her parents are likely to be frustrated with her. The entire family may be tired of the frequent confrontations and outbursts. Helping this young lady understand the consequences of her behavior, and exploring those comparisons which are making her feel "fat," may be fruitful and prevent full-blown anorexia. She's not lacking motivation because she is "an unmotivated person." She is not motivated to change because her illness is beginning to take over her logic and reasoning. Imagine this teen without ever receiving any treatment until her late twenties. How will she even get into treatment at that point? What will it take to break her denial at that point? Remaining in denial can only lead to failure.

I have had obese patients who are mandated by their physician to attend therapy because of their failing health. Despite not coming to therapy on their own, they can make gains. For example, there is a high rate of depression among some obese patients, which makes them feel even more helpless and overwhelmed. Fatigue is also a symptom of depression that could make an obese person unable to take the initiative for treatment, never mind exercise. Treating the depression in this case would be the initial treatment goal. If a person is depressed, all the "willpower" in the world may not get this person to do what they need to do.

I have had overweight people say, "Please don't let me gain weight back, I can't bear the thought... I'd rather not even try anymore." This is a true and paralyzing fear. On some level, this person already knows that their motivation is not a constant. The problem is not their waning motivation. The problem is that they expect their motivation not to wane. In substance abuse treatment, the American Society for Addiction Medicine stresses the importance of tailoring interventions and treatment expectations to match a patient's individual degree of motivation. An individual's level of motivation will wax and wane depending upon factors such as stress level, social support, and financial resources. Since obesity may be a lifelong struggle for some, patients have to expect their motivational level to fluctuate. Expecting these fluctuations and learning to accept them is crucial to long-term weight loss. That is why I recommend "planned plateaus." These are periods of time in between losing small amounts of weight in which the goal is to stop losing and maintain the weight already lost. I recently instructed a patient to stop losing after every five pounds dropped. It was the only way she could prove to herself that she had the skills and ability to keep weight off.

So, even if you are being forced to read this book or if someone tactfully slipped it into holiday gift-wrap, somebody is concerned. Somebody loves you and wants you to take the first step... which you already did, by the way. There is only one way to "fall off the wagon." It's not by eating too much at a picnic, making a visit to McDonald's, or by eating when you are stressed. The only way to fail at this program is to not give yourself a chance. So let's begin.