Understanding the Skills to support Behaviour Change
The skills needed to support behaviour change are essentially an attention to our own communication style, both verbally and non-verbally to the person with the Eating Disorder, ‘It’s not just what you say, it’s the way that you say it.’
Motivational Interviewing is a style of ‘being’ with someone to support them in the Change Process. The psychological theory of change applied in Motivational Interviewing is called the ‘Transtheoretical Model of Change’. This is not just a model for ‘ill’ people, it is a model which explains how we all approach change. It is important to recognise that an individual who is in the process of change will return to any of these stages before they are able to maintain the changes, the final step. It is naturally a 2 steps forward, 1 step back process. So some personal resilience is required to keep moving forward in small steps. Consider these stages and how they relate to Eating Disorders (see Animal Analogies page for further reference).
Precontemplation refers to behaviour which is characterised by a belief that there is nothing wrong, or to minimise the health problem. Other people’s concerns are experienced as critical or wrong or misguided. While in this stage the individual only has one mindset and the eating disorder is often viewed as the solution and not the problem. “My eating is my business.” Only Dolphin or St Bernard care will work here.
Contemplation is often a stage of distress for the person with the eating disorder. This is when the individual is in two minds. They feel confused and fearful and often give out ‘mixed messages’. A key skill is to listen to (not agree with) what the positive feelings and solutions the Eating Disorder is giving to the person. It is these positives that will prevent the person from embarking on change, and it is these positives which will confuse and worry them because it places them at odds with the rest of the world. There is no mileage in arguing with Rhino logic, or covering up the confusion with Kangaroo care, or becoming distressed and emotional like the Jellyfish or avoiding the conflicting issues like the Ostrich. Your job is to help the person to consider achieving the same positive feelings by developing a repertoire of other behaviours, which could provide similar comfort and positive feelings.
Determination and Preparation refers to the stage where the person builds on their self confidence and identifies any skills or support needed to implement any change experiments. They will need help to do this as we know that everyone with an Eating Disorder has a core sense of low self esteem and self belief. We have to show them that we trust them to learn and get things wrong and learn again and again from this experience. Patience and calmness count. A focus on a perfect outcome or a plan which tries to include all eventualities will not work. Tolerating a ‘good enough’ plan is part of this preparation. Use the acronym SMART (see glossary) when setting small experiments.
Action this is the stage when people try out small experiments, without any emphasis on the outcome. This is about learning to take risks ie control shifts away from the eating disorder providing the safety net. ‘Every Mistake is a Treasure’. Learn from these experiments; sift out what worked and what didn’t work. Understand what is needed to tolerate a less than perfect outcome, ‘failure’ should be reframed as ‘generating more information to try again’.
Maintenance is when the individual continues to sift out bits from each new experiment and tries again and again e.g. keeping the meals going even when they are low or tired or anxious. They can consider food as their medication. They can develop strategies to challenge a negative body image or any other hurdle that perhaps was less apparent when their weight was lower or their bingeing was more out of control. You will hold the hope for your loved one. So being in a calm, energised, positive space is important. ****It is important to understand each stage and identify which stage you are at yourself, compared to your loved one. Carers are often in Action mode only and the discrepancy will create arguments and be seen as confrontational if not understood. Arguments and confrontation will not achieve change. Being alongside someone does not mean you agree with their behaviour. In this model it means you understand what they are giving up if they embark on behaviour change. This is very difficult for all Carers to understand and can feel counter intuitive.
**** Ask yourself ‘Is what I am doing working? If the answer is yes continue, if the answer is no, role model trying something different. In the DVD we are attempting to demonstrate several concepts:
• Discussing food, weight and shape gives the message that eating is negotiable, when it is not for anyone
• The strength in role modelling being able to change behaviours
• The need to try a communication technique which may not feel natural or easy
• The need to pay attention to the psychological benefits of having an eating disorder
• The research findings that people with eating disorders pay great attention to details and struggle with the ‘bigger picture’ and that they often do this to manage their anxiety and fear
Listening and questioning techniques
Real listening can be a challenge when giving and a gift when receiving. Definite proof that we are listening, hearing and understanding what a person has said is one of the fundamental components of our intervention. We use reflective listening techniques to reflect the person’s statement back to them as well as summarizing our interpretation of their utterance.We encourage carers to listen to what their loved one is telling them before saying it back in a different form. This then gives their loved one the opportunity to either agree or disagree with their interpretation of what has just been said.
Sufferer: You just sometimes feel so alone in all of this, like there’s no future…no way out.
Carer: So you’re feeling trapped.
Sufferer: That’s exactly how I feel.
Note the above example reflects not the exact words that the sufferer has used, but the gist of the message. The carer has interpreted his/her words as what might be meant or thought. Reflections need not and are not often restricted to what the person has said directly. Reflections are statements not another question. Reflections are not followed by advice about how to reduce the uncomfortable feelings.
When engaging in reflective listening, it quickly becomes apparent that decisions have to be made on what is reflected back. Undoubtedly, there will be a rich array of possibilities and it soon becomes evident that not all can be reflected upon. Reflective listening, may be challenging initially, particularly during times of high emotions. Until the carer feels comfortable with the process, it may easier to practice these skills during calmer periods, e.g. outside mealtimes. Reflective listening can be surprisingly effective in helping people change (2). In motivational interviewing what one chooses to reflect back can make a difference. ‘Simple’ and ‘Complex’ reflections are two basic components of motivational interviewing:
The Acronym for this type of listening is OARS
The atmosphere you are trying to create through this type of communication is one where you can both tolerate differences of opinion without being angry, critical, irritated and blaming. We want you to side with your loved one’s qualities and strengths, so that in time they build up the confidence to embark on change. The pitfalls are described in the Animal Models section.
Open questions
Open questions are about opening up the conversation or thoughts, and moving away from the detail focus favoured by the eating disorder. They are also a creative way of ‘planting seeds’ of ideas and suggestions without seeking an immediate commitment. Open questions are always non-judgmental and non-threatening, thus allowing the individual to run through their ideas in confidence. As a general rule, open questions tend to begin with words like “who, what, how, when and where”. ‘Why’ questions almost invariably turn into closed questions. Openings such as “tell me” and “describe to me” ‘’I am interested in your thoughts’’ are also effective.
• I've noticed that your portions are smaller than those recommended on your meal plan, yet you've asked me to help you with your university application. I'm a bit confused as to how you will reconcile these two areas. What are your feelings about this? o This reflection + open question is aimed at promoting a greater sense of self-reflection.
• I get the feeling that your anxiety levels are high tonight. What ways can I support you in bringing them back down to a more manageable level? o This question is more likely to open up and expand on how they see the way they deal with their eating disorder.
• I'm interested in how you feel after your therapy. How would you feel about sharing your thoughts on any effects? o This question invites the sufferer to talk about any feeling he/she may wish to share. • Tell me a bit about any obstacles you think may challenge you? o Again this question is more likely the recipient to use his/her own creative skills in coming up with an answer or an action plan as to how to deal with any challenges that may lie ahead.
• What options would you like to have? o This introduces the idea of choice and empowerment and reduces the feeling of being ‘trapped’.
Closed questions
In normal communication, closed questions are an efficient way of gathering specific information. The answer we anticipate when asking a closed question is usually brief. Here are a few examples:
1. Can you please eat a little more?
2. Are you feeling more anxious this evening?
3. Do you feel your therapy is working for you?
4. Do you have a problem solving strategy?
Closed questions limit the answers. They generally elicit simple one word answers or a yes/no response. They bring an end to the line of questioning, prompting the necessity for more questioning. Closed questions literally close down the interaction.
Affirmations These are comments we make which can reinforce a sense of self-confidence and self-belief. They focus on the other person’s efforts – ‘you have put a lot of thought into planning that outing’, or their intentions - ‘it is a special skill to see things from several perspectives and consider doing things differently’, or their thought processes – ‘weighing up the pros and cons and considering trying a different approach takes courage’. Demonstrating that you know they have strengths, or that they have weaknesses which they are trying to manage, make these comments very powerful. Don’t expect the eating disorder part of the person to like what you have said, and they may try and dismiss or belittle your affirmation, hold fast you have planted a valuable seed. You can make your own list of your loved one’s qualities eg. tenacious, caring, thoughtful, passionate etc. Turn what you see as their negative behaviour into a positive eg. Being argumentative, means the person can weigh up the pros and cons.
Reflections - simple These demonstrate to the person that you have heard what they have said, and not ascribed negative motives, or misunderstood them. A simple reflection is a repeat of the actual words used, and comes in handy when you are lost for words. The tone must be neutral, and non judgemental. Sufferer: I’m trying to kind of …not be so much like that…by planning on talking to my GP, I’m trying to kind of show myself I can take care of myself and that I’m getting sorted out Carer: So you are planning to talk to your GP, so that you can show that you can take care of yourself and that you are getting sorted out
Reflections - complex Complex reflections involve taking a reflection and adding something to it. This is where you feed back what the person is saying, but add a bit onto it, usually increasing the intensity. The skill lies in choosing what to intensify. It is usually the resistant element that you choose to intensify.
Sufferer: Actually maybe even speaking with David, about what I would hope could be a plan for us as a family. Yeah because if I’m going to talk with him I need to know in my own mind that he will take some of the strain away from me. And maybe together, maybe he has ideas as well and I think it’s important for him to hear what I’m saying. Because you know at times I’ve not talked with him, I’ve been so involved with myself and, to an extent, excluded him.
Carer: So if I've got it right, you're saying you would like to talk to David about your thoughts and ideas so that he might be able to give you another perspective of how to break from this trap and help take the strain away from you and he would feel more included in the relationship with you (Complex reflection and a summary)
Summaries
Summaries are a string of utterances joined together and repeated back as a bouquet of reflections and need to be done quite often, as we can lose the thread of the conversation very quickly and then misunderstandings develop.
Sufferer: Actually maybe even speaking with David, about what I would hope could be a plan for us as a family. Yeah because if I’m going to talk with him I need to know in my own mind that he will take some of the strain away from me. And maybe together, maybe he has ideas as well and I think it’s important for him to hear what I’m saying. Because you know at times I’ve not talked with him, I’ve been so involved with myself and, to an extent, excluded him.
Carer: You care about your relationship with David, even though up to now you feel you have been very wrapped up in yourself. You are hoping that together you can share your ideas for your hopes for the family. You intend to do this by talking to him and asking for help to manage the strain you feel.
Developing discrepancy: Here motivational interviewing is used to create and amplify a discrepancy between present behaviour and broader goals and values, i.e. future goals and the present state of affairs.
Sufferer: I don't know why you're on my back so much. I just don't feel like eating. I'm huge and if it was up to you, you'd have me stuffing myself like a pig....
Carer: I guess dad and I are a bit confused. You were speaking last night about how much you were looking forward to starting university in October, yet you've been losing weight at an alarming rate and your doctor has told you that you may have to be admitted to hospital unless you gain some. (you do not go on to say – ‘and this is what you should do..’ this will prevent self reflection)
Also do not back a person into a corner by insisting on an answer. You leave the person to consider their behaviour. It is always helpful to quote an objective measure of deepening illness, which has nothing to do with speculation or personal opinion, and preferably not weight related eg. ‘It seems as though you are becoming more and more tired’ or `I notice that you are struggling more than usual to manage your anxiety’. It is not necessary to expect a coherent, positive answer. You have planted the seed of your concern.
This scenario exemplifies the skills we are teaching carers to use with their loved one with an eating disorder. Here the carer develops discrepancy between her daughter's/son’s goals and dreams for the future that are important to her/him and the current behaviour. When skilfully and gently done, developing discrepancy can change the person's perceptions without creating any sense of being pressured or coerced into a new behaviour.
Support self-efficacy:
Self-efficacy refers to the person's belief in his or her ability to carry out and succeed with a specific task. Self efficacy is a key element in motivation for change and is a reasonably good predictor of treatment outcome.
Sufferer: I just find life so very tough, my mind is just so jumbled up 24/7 with food, calories, weight, I try to hard...and nothing seems to take these thoughts away.
Carer: I can imagine it's pretty tough for you. However, I also know that you've always been such a determined person and strong too and that you can think of other ways to beat this.
Helping someone with an Eating Disorder build their self confidence will help them to step into the frightening waters of change and try out small experiments and tolerate a less than perfect outcome.
Motivational Interviewing does not prevent you from carrying out your role as a caring parent or carer. The message is that you need to be clear with your Loved One what your role is and how you are going to carry it out, with compassion, thoughtfulness and clarity. How you are going to focus on health and help the person to learn to look after themselves in the same way they would expect you to care for yourself. It is true they have difficulties in giving up behaviours they find comforting, and help them make sense of the world. We need to show them that everyone has these conflicts, in varying degrees and that there is a benefit in broadening our repertoire of managing these challenges, through using our interpersonal relationships and remaining connected to other people.
If you would like to know more about Motivational Interviewing you can read: Ref 1 ‘Motivational Interviewing:helping people change. 3rd Edition’ By William R Miller and Stephen Rollnick. 2013 pub. The Guilford Press. Ref 2: ‘Skills-based Learning for Caring for a Loved One with an Eating Disorder’ By Janet Treasure, Grainne Smith and Anna Crane . 2007 Pub. Routledge