Collaborative care in eating disorders treatment: exploring the role of clinician distress, self-compassion, and compassion for others.

BACKGROUND: Collaborative care is described as showing curiosity and concern for patient experiences, providing choices, and supporting patient autonomy. In contrast, in directive care, the clinician has authority and the patient is expected to adhere to a treatment plan over which they have limited influence. In the treatment of eating disorders, collaborative care has been shown to be more acceptable and produce better outcomes than directive care. Despite widespread patient and clinician preference for collaborative care, it is common for clinicians to be directive in practice, resulting in negative patient attitudes toward treatment and poor adherence. There is a need to understand factors which contribute to its use. PURPOSE: This study examined the contribution of clinicians' experience of distress and how they relate to themselves and others in times of difficulty (self-compassion and compassion for others), to their use of collaborative support. METHOD: Clinicians working with individuals with eating disorders from diverse professional backgrounds (N = 123) completed an online survey. RESULTS: Whereas clinician distress was not associated with use of collaborative or directive support behaviours, self-compassion and compassion for others were. Regression analyses indicated that compassion for others was the most important determinant of collaborative care. DISCUSSION: Relating to their own and others' distress with compassion was most important in determining clinicians' use of collaborative support. Understanding how to cultivate conditions that foster compassion in clinical environments could promote the delivery of collaborative care.

Self-compassion and its barriers: predicting outcomes from inpatient and residential eating disorders treatment.

BACKGROUND: Individuals with eating disorders (EDs) experience barriers to self-compassion, with two recently identified in this population: Meeting Standards, or concerns that self-compassion would result in showing flaws or lead to loss of achievements or relationships, and Emotional Vulnerability, or concerns that self-compassion would elicit difficult emotions such as grief or anger. This exploratory study examined the utility of self-compassion and two barriers to self-compassion in predicting clinical outcomes in intensive ED treatments. METHOD: Individuals in inpatient (n = 87) and residential (n = 68) treatment completed measures of self-compassion and fears of self-compassion, and ten clinical outcome variables at pre- and post-treatment. RESULTS: Pre-treatment self-compassion was generally not associated with outcomes, whereas pre-treatment self-compassion barriers generally were. In both treatment settings, fewer Emotional Vulnerability barriers were associated with improved interpersonal/affective functioning and quality of life, and fewer Meeting Standards barriers were associated with improved readiness and motivation. Interestingly, whereas Meeting Standards barriers were associated with less ED symptom improvement in inpatient treatment, Emotional Vulnerability barriers were associated with less ED symptom improvement in residential treatment. CONCLUSIONS: Given that few longitudinal predictors of outcome have been established, the finding that pre-treatment barriers to self-compassion predict outcomes in both inpatient and residential settings is noteworthy. Targeting self-compassion barriers early in treatment may be helpful in facilitating ED recovery.

Self-compassion is associated with a number of positive health indicators and has been shown to support recovery from an eating disorder. This exploratory study examined whether self-compassion and barriers to self-compassion predict clinical outcomes in inpatient and residential eating disorders treatment settings. Whereas self-compassion was rarely associated with outcome, self-compassion barriers were associated with the majority of variables investigated. Given that few longitudinal predictors have been established in this field, the relation between barriers to self-compassion and outcome in both inpatient and residential settings is noteworthy. Targeting self-compassion barriers early in treatment may be helpful in facilitating eating disorder recovery.

Path to practising self-compassion in a tertiary eating disorders treatment program: A qualitative analysis.

OBJECTIVE: Although self-compassion has been shown to facilitate eating disorder (ED) remission, significant barriers to acquiring this skill have been identified. This is particularly true for tertiary care populations, where ED behaviours provide a valued identity and readiness issues are highly salient. In this research, the voices and perspectives of patients who have recovered as well as those in later stages of tertiary care treatment were captured using qualitative methods. METHODS: Seventeen individuals with a lengthy ED history (seven fully recovered, 10 currently in recovery-focused residential treatment) participated in audio recorded interviews. Using a visual timeline, participants described the development of their understanding of self-compassion, barriers to self-compassion and how these barriers were overcome. RESULTS: Three processes were identified, reflecting different levels of readiness. Challenging my beliefs involved overcoming cognitive barriers to the concept of self-compassion (i.e. coming to see self-compassion as helpful), and set the stage for dealing with the world around me and rolling up my sleeves, which reflected preparatory (i.e. freeing oneself from difficult life circumstances) and active (i.e. having the courage to do the work) change efforts, respectively. CONCLUSIONS: These findings may help patients embarking on tertiary care treatment to envision a roadmap of supportive processes and help clinicians tailor interventions to patient level of readiness for self-compassion.

Is experiencing care as collaborative associated with enhanced outcomes in inpatient eating disorders treatment?

In eating disorders inpatient care, mandatory treatment components are central to effective service delivery. Thus, fostering a collaborative care environment that supports autonomy, competence, and connection can be challenging. This study examined whether collaborative care is associated with better outcomes in adult inpatient treatment and explored a possible determinant of collaborative care, the manner in which mandatory treatment components were delivered (e.g. consistent implementation of weight gain guidelines, provision of choices regarding intensity of treatment). Inpatients (N = 146) completed measures of eating disorder symptoms, psychological functioning and readiness and motivation for change, pre and post-treatment. At post, they also completed measures of collaborative care, treatment satisfaction, and a new measure designed to evaluate patients' experiences of mandatory treatment components. After controlling for baseline symptom levels, multiple regression analyses determined that collaborative care was associated with improvements in nearly all symptom domains. Collaborative care was also associated with patient satisfaction and the manner in which mandatory treatment components were delivered (e.g. consistency, provision of choices). In sum, a collaborative environment was associated with improvements in motivation, eating disorder symptoms, and psychiatric functioning and one way in which this may be achieved is in the manner in which mandatory treatment components are delivered.

The relation between two barriers to self-compassion and clinical characteristics in individuals with eating disorders.

There is growing support for the role of self-compassion in recovery from an eating disorder (ED) and two types of barriers have been identified in this population: (a) fears that self-compassion will result in a failure to meet personal and interpersonal standards (meeting standards); and (b) fears that self-compassion gives rise to difficult emotions such as grief and unworthiness (emotional vulnerability). OBJECTIVE: This research examined the relative contribution of meeting standards and emotional vulnerability barriers to the clinical characteristics of individuals with EDs. METHOD: Participants (N = 349) completed the fears of compassion for self-scale, and measures of self-compassion, ED and psychiatric symptom severity, interpersonal and affective functioning, quality of life and readiness for ED change. RESULTS: Together, the two barrier types accounted for significant variance in all study variables. Meeting standards was associated with lower readiness to change and greater over-control. In contrast, emotional vulnerability was associated with lower self-compassion, readiness, and quality of life, poorer interpersonal and affective functioning, and greater ED and psychiatric severity. CONCLUSION: While both barriers to self-compassion were related to functioning in individuals with EDs, the emotional vulnerability barrier accounted for more variance in pathology and may be most beneficial to target in treatment.

Barriers to self-compassion in the eating disorders: The factor structure of the fear of self-compassion scale.

Individuals with eating disorders (EDs) endorse fears of being self-compassionate, as assessed by the Fears of Compassion for Self scale (FCSelf; Gilbert, McEwan, Matos, & Rivis, 2011), and higher fears predict poorer treatment outcomes. Previous research using the FCSelf demonstrated a single factor solution in a non-clinical sample. OBJECTIVES: This research sought to explore the factor structure of the FCSelf in a clinical population and to examine correlations with associated constructs. The factor structure obtained was compared with its structure in a student sample. METHODS: Individuals with EDs (n = 251) completed the FCSelf, and measures of readiness to change, self-compassion, quality of life, as well as psychiatric and ED symptom severity. A female student sample (n = 314) completed the FCSelf. RESULTS: In the clinical sample a two-factor solution exhibited best fit. Factor 1, labeled "Meeting Standards," contained items expressing concern about showing flaws and losing achievements and relationships. Factor 2, labeled "Emotional Vulnerability," contained items focusing on difficult emotions such as grief, unworthiness, and vulnerability. The two subscales exhibited acceptable internal consistencies and were significantly correlated with clinical outcome variables. In the student sample, the two factor model was superior to a single factor model but given that the latent correlation was so high (r = 0.89) a single summary score is recommended. CONCLUSION: Future research is needed to determine the value of addressing barriers related to meeting standards versus emotional vulnerability in helping individuals with EDs develop self-compassion and recover from their illness.

Is stage of change enough? Confidence as a predictor of outcome in inpatient treatment for eating disorders.

OBJECTIVE: While stage of change has been shown to be a robust predictor of eating disorder treatment outcome, little attention has been paid to the role of confidence. This study sought to better understand the role of confidence and the possible interaction it may have with stage of change in promoting eating disorder symptom change. METHOD: Participants were adult women in inpatient treatment for eating disorders. They completed measures of motivation for change, which assessed precontemplation, action, confidence and internality (changing for oneself vs. others) and eating disorder symptom severity at pretreatment (N = 159) and posttreatment (n = 59). Only treatment completer analyses were used. RESULTS: Precontemplation and confidence had significant effects on pretreatment and posttreatment symptom severity, while action only had a significant effect on pretreatment symptoms. Confidence was shown to moderate relations between both measures of stage of change (i.e., precontemplation and action) and symptoms posttreatment. Follow-up analyses indicated that high precontemplation was associated with poor outcome, irrespective of confidence, however, low precontemplation was associated with better outcome at high levels of confidence. The interaction between confidence and action was also significant at very high levels of confidence. That is, among individuals who had high action at baseline, those with low confidence had significantly poorer outcomes relative to those with high confidence. DISCUSSION: Findings indicate that stage of change and confidence are both important prognostic factors and suggest that early behavior change in the absence of confidence may not guarantee best outcomes in inpatient eating disorder treatment.

The Short Treatment Allocation Tool for Eating Disorders: current practices in assigning patients to level of care.

OBJECTIVE: The Short Treatment Allocation Tool for Eating Disorders (STATED) is a new evidence-based algorithm developed to match patients to the most clinically appropriate and cost-effective level of care (Geller et al., 2016). The objective of this research was to examine the extent to which current practices are in alignment with STATED recommendations. METHOD: Participants were 179 healthcare professionals providing care for youth and/or adults with eating disorders. They completed an online survey and rated the extent to which three patient dimensions (medical stability, symptom severity, and readiness) were used in assigning patients to each of five levels of care. RESULTS: The majority of analyses testing a priori hypotheses based on the STATED were statistically significant (all p's < .001), in the direction of STATED recommendations. However, a strict coding scheme evaluating the extent to which ratings were fully consistent with the STATED showed inconsistency rates ranging from 17 to 55% across the five levels of care, with the greatest inconsistencies involving the use of readiness information, and the lowest involving the use of medical stability information. DISCUSSION: Although practices were generally aligned with the STATED recommendations, readiness information was used least consistently in assigning patients to level of care.

The relation between patient characteristics and their carers' use of a directive versus collaborative support stance.

OBJECTIVES: Collaborative support provided by carers (family and friends) of individuals with eating disorders has been shown to be integral to patient motivation and clinical outcome. Little is known about factors that contribute to carers' use of collaborative, as opposed to directive, support stance. This exploratory research investigated associations between patient characteristics and carers' support beliefs and behaviors. METHOD: Eating disorder patients (n = 72) completed measures of readiness for change, eating disorder, and psychiatric symptom severity, and interpersonal functioning. Their carers (n = 72) completed measures of collaborative and directive support. RESULTS: Patient demographic variables, readiness for change, and psychiatric symptom severity were not associated with carer beliefs or behaviors. However, some patient interpersonal functioning scores were; higher Domineering/Controlling scores were associated with carers viewing directive support as more helpful, and with their use of more directive support behaviors. Higher Vindictive/Self-Centered and Intrusive/Needy scores in patients were also associated with carers viewing directive support as more helpful. DISCUSSION: This exploratory study suggests that carers may be more prone to utilizing a directive, rather than a collaborative, support stance with patients experiencing higher levels of threat, anger, and hostility, and lower levels of safety, closeness, and trust.

The readiness and motivation interview for families (RMI-Family) managing pediatric obesity: study protocol.

BACKGROUND: Experts recommend that clinicians assess motivational factors before initiating care for pediatric obesity. Currently, there are no well-established clinical tools available for assessing motivation in youth with obesity or their families. This represents an important gap in knowledge since motivation-related information may shed light on which patients might fail to complete treatment programs. Our study was designed to evaluate the measurement properties and utility of the Readiness and Motivational Interview for Families (RMI-Family), a structured interview that utilizes a motivational interviewing approach to (i) assess motivational factors in youth and their parents, and (ii) examine the degree to which motivation and motivation-related concordance between youth and parents are related to making changes to lifestyle habits for managing obesity in youth. METHODS: From 2016 to 2020, this prospective study will include youth with obesity (body mass index [BMI] ≥97th percentile; 13-17 years old; n = 250) and their parents (n = 250). The study will be conducted at two primary-level, multidisciplinary obesity management clinics based at children's hospitals in Alberta, Canada. Participants will be recruited and enrolled after referral to these clinics, but prior to initiating clinical care. Each youth and their parent will complete the RMI-Family (~1.5 h) at baseline, and 6- and 12-months post-baseline. Individual (i.e., youth or parent) and family-level (i.e., across youth and parent) responses to interview questions will be scored, as will aspects of interview administration (e.g., fidelity to motivational interviewing tenets). The RMI-Family will also be examined for test-retest reliability. Youth data collected at each time point will include demography, anthropometry, lifestyle habits, psychosocial functioning, and health services utilization. Cross-sectional and longitudinal associations between individual and family-level interview scores on the RMI-Family and these clinical measures will be examined. DISCUSSION: As a measurement tool drawing on family-centered care and motivational interviewing, the RMI-Family was designed to increase understanding of the role of motivational factors in pediatric obesity management, allowing healthcare providers and policymakers to manage pediatric obesity more effectively and efficiently. Findings will help to create an innovative, tailored model of health care delivery that uses resources judiciously and is designed to best meet families' needs.

Social support satisfaction in adults with eating disorders: Does stance matter?

Although the role of social support is clearly established in the recovery of youth with eating disorders, little is known about factors that contribute to support satisfaction and improved treatment outcome in adults. This study examined the contribution of patient factors and perceived support stance used by family and friends in determining social support satisfaction. Individuals meeting DSM-IV criteria for an eating disorder (n = 182) completed measures of eating disorder and psychiatric severity, interpersonal functioning, perceived support stance used by family and friends, and social support satisfaction. Correlations indicated that both patient factors (lower psychiatric distress and fewer interpersonal difficulties) and perceived support stance (higher concerned and lower directive support) were associated with patient support satisfaction. Multiple regression analyses indicated that perceived support stance accounted for greater variance in social support satisfaction than did patient factors. Patient age was associated with differences in preferred support stance: expressions of caring were most critical for younger patients, whereas not being criticized or told what to do was most significant for older patients. This research suggests that the stance used when offering support is vital to the care of individuals with eating disorders.

Support stance in carers of adults with eating disorders: Factors associated with collaborative versus directive approaches.

The support provided by family and friends is integral to patient motivation and clinical outcomes across health care populations. However, little is known about factors that promote or interfere with the type of support offered. OBJECTIVE: This research examined factors associated with collaborative versus directive support among carers of adults with eating disorders. METHOD: Participants were mothers, fathers, partners, friends, and siblings (N = 141) of eating disorder patients in hospital or residential treatment. Two methodologies were used to assess directive and collaborative support stance: a questionnaire of support behaviors and coded responses to clinical vignettes. Measures of interpersonal functioning, psychiatric distress, caregiving experience, and closeness with their loved one were also completed. RESULTS: Although carers rated a collaborative stance as more helpful than a directive stance, 60% of responses to the clinical vignettes were directive. Across both methodologies, collaborative support behaviors were associated with beliefs about helpful support and with a less vindictive and cold interpersonal style. Whereas use of a directive support stance was exclusively associated with negative caregiving experiences, collaborative responses were associated with both positive and negative experiences. DISCUSSION: Although the benefits of collaborative support have been well established, this is the first study to examine factors associated with the use of support stance. Findings suggest a number of ways to help carers create and maintain collaborative relationships, including addressing beliefs and interpersonal style and capitalizing on both positive and negative experiences with their loved one. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:498-505).

Developing and Pilot Testing the Readiness and Motivation Interview for Families in Pediatric Weight Management.

Clinical acumen is often used to assess families' motivation prior to initiating pediatric obesity management due to a lack of available tools. The purpose of this pilot study was to (i) develop and (ii) pilot test the "Readiness and Motivation Interview for Families" (RMI-Family) in pediatric weight management. We conducted 5 focus groups with parents (n = 15), youth with obesity (n = 11), and health care providers (n = 8) to explore perceptions of barriers to making healthy behaviour changes, which led to the creation of the RMI-Family as a semi-structured interview. Five domains (treat foods, overeating, emotional eating, total physical activity, and screen time) emerged from the focus groups to inform the development of the RMI-Family, which was then pilot tested with a sample of youth with obesity and their parents (n = 11 dyads). Interviewers administered the RMI-Family to youth (age 12.8 ± 1.7 years; body mass index [BMI] z-score: 2.71 ± 0.43) and parents (age 47.1 ± 3.7 years; BMI: 33.5 ± 10.1 kg/m(2)). The RMI-Family was feasible to administer, easily understood by families, and may be a useful tool for assessing families' motivation. Research is underway to determine the psychometric properties and utility of the RMI-Family in predicting clinical outcomes in pediatric weight management.

The psychometric properties of the Readiness and Motivation Questionnaire: a symptom-specific measure of readiness for change in the eating disorders.

Readiness for change, as assessed by the readiness and motivation interview (RMI), predicts a number of clinical outcome variables in eating disorders including enrollment in intensive treatment, symptom change, dropout, and relapse. Although clinically useful, the training and administration of the RMI is time consuming. The purpose of this research was to (a) develop a self-report, symptom-specific version of the RMI, the readiness and motivation questionnaire (RMQ), that can be used to assess readiness for change across all eating disorder diagnoses and (b) establish its psychometric properties. The RMQ provides stage of change, internality, and confidence scores for each of 4 eating disorder symptom domains (restriction, bingeing, and cognitive and compensatory behaviors). Individuals (N = 244) with current eating disorder diagnoses completed the RMQ and measures of convergent, discriminant, and criterion validity. Similar to the RMI scores, readiness scores on the RMQ differed according to symptom domain. Regarding criterion validity, RMQ scores were significantly associated with ratings of anticipated difficulty of recovery activities and completion of recovery activities. The RMQ contributed significant unique variance to anticipated difficulty of recovery activities, beyond those accounted for by the RMI and a questionnaire measure of global readiness. The RMQ is thus an acceptable alternative to the RMI, providing global and domain-specific readiness information when time or cost prohibits use of an interview.

The efficacy of a brief motivational intervention for individuals with eating disorders: a randomized control trial.

OBJECTIVE: Individuals with eating disorders are often ambivalent about recovery, and previous research has shown that readiness for change predicts enrollment in intensive treatment, symptom change, dropout, and relapse. Given the demonstrated importance of readiness for change, researchers and clinicians have turned to investigating interventions designed to enhance motivation. The purpose of this research was to determine the efficacy of Readiness and Motivation Therapy (RMT), a five-session individual preparatory intervention for individuals with eating disorders. METHOD: Participants completed the Readiness and Motivation Interview and measures of eating disorder symptomatology, self-esteem, and psychiatric symptoms at intake. One hundred eighty-one participants were randomly assigned to the treatment (RMT) or wait-list control condition and were reassessed at 6-week and 3-month follow-up; 113 completed assessments at all three time points and primary analyses were based on these individuals. RESULTS: Surprisingly, improvements in readiness for change, depression, drive for thinness, and bulimia symptoms occurred over time in both RMT and control conditions. However, at post and at follow-up, individuals who received RMT were less likely to have high ambivalence than were those from the control condition. DISCUSSION: RMT may be of benefit to highly reluctant, clinically challenging patients and help them make better use of future, action-oriented treatment.

Factors associated with improvements in readiness for change: low vs. normal BMI eating disorders.

OBJECTIVE: To examine factors associated with improvements in readiness for change as a function of body mass index (BMI) in individuals assessed for eating disorders treatment. METHOD: Participants (n = 128) completed the Readiness and Motivation Interview (RMI) and measures of psychiatric and eating disorder symptoms, quality of life, and self-esteem at baseline and at 5-month follow-up. RESULTS: Participants whose readiness for change showed improvements in psychiatric symptom severity, global self-esteem, and in the importance of friendships as a determinant of self-esteem. Only those with a normal baseline BMI (20 kg/m(2) or greater) improved in eating disorder symptoms and quality of life, and reported increased importance of personal development and decreased importance of shape and weight as determinants of self-esteem. CONCLUSION: Correlates of readiness differed between low and normal BMI participants, suggesting that weight status may be an important variable to consider in preparing highly ambivalent individuals for treatment.

Readiness to change dietary restriction predicts outcomes in the eating disorders.

This study examined the relationship between readiness and motivation to change eating disorder symptoms and clinical outcomes during and following intensive residential eating disorder treatment. Sixty-four women completed the Readiness and Motivation Interview (RMI) at baseline, and a subset of participants were reassessed at post-treatment (n=45) and at 6 month follow-up (n=38). The RMI provides readiness scores for each of four symptom domains: restriction, cognitive, bingeing, and compensatory strategies. RMI scores were used to predict decision to enroll in treatment, dropout, symptom change following treatment, and maintenance of symptom change at six-month follow-up. The extent to which participants did not want to make changes to their dietary restriction at baseline (restriction precontemplation) was the most consistent predictor of short-term clinical outcome. The extent to which participants reported changing their restriction for themselves versus others (restriction internality) predicted outcome at 6-month follow-up. These preliminary findings suggest that assessing client readiness and motivation to change dietary restriction is most useful in predicting short and long-term clinical outcomes.

Beyond shape and weight: exploring the relationship between nonbody determinants of self-esteem and eating disorder symptoms in adolescent females.

OBJECTIVE: Recent research using the Shape and Weight-Based Self-Esteem (SAWBS) Inventory has shown that basing self-esteem on shape and weight is related to eating disorder and psychiatric symptoms. This study examined the relationship between other determinants of self-esteem assessed in the SAWBS Inventory (e.g., friendships, intimate relationships, school/work competence) and eating disorder and psychological health variables. METHOD: Female high school adolescents (N = 235) participated in this study. The relative contribution of the self-esteem dimensions to eating disorder and self-esteem was examined. RESULTS: In addition to shape and weight, basing self-esteem on intimate relationships was also related to higher eating disorder symptoms and lower body and global self-esteem. The only protective factors to emerge in this study were basing self-esteem on competence at school and other activities. DISCUSSION: Basing self-esteem on intimate relationships was associated with similar physical and health problems to basing self-esteem on shape and weight. The implications of these findings with regard to healthy adolescent development are addressed.