Readiness and Motivation Models for Friends and Family
Friends and family members have the potential to promote recovery for individuals who have eating disorders. Unfortunately, the social support literature suggests that when attempting to be helpful, it is common for support providers to unintentionally say or do things that are viewed by the recipient as unhelpful. Although outside support is considered an important component of treatment, studies suggest that eating disorder patients receive less emotional and practical support than comparison groups and perceive the assistance that they do receive as inadequate.1,2
Conflicting Support Perspectives
Individuals with eating disorders are often ambivalent about making changes, and this lack of motivation has been associated with high levels of treatment refusal, dropout, and relapse. Thus, it is not surprising that support providers of individuals with severe eating disorders experience more distress and difficulty in their role than do caregivers of other psychiatric illnesses.3 Caregivers and friends of those with severe eating disorders frequently report frustration with trying to support the individual in recovery, and state that the complexity and ambivalence associated with these illnesses cause them to experience significant distress.
The considerable ambivalence often expressed by individuals with eating disorders has led to treatment approaches that maximize patient autonomy and readiness for change. Research shows that eating disorder patients and their health-care providers view collaborative treatment approaches as more acceptable and more likely to produce positive outcomes than approaches that are more directive and less flexible. Similarly, studies indicate that friends and family also view collaborative support as more helpful than controlling support. However, despite the desire of friends, family, and health-care providers to offer support, all groups believe that directive and controlling interactions frequently occur in both treatment and social settings.
This discrepancy between what support providers believe to be most helpful and what is actually occurring prompted us to further explore this issue with our patients. Over the past year, we asked patients participating in outpatient eating disorders groups to describe what they would like from their family and friends. Several key themes emerged from these discussions that were congruent with research findings. What follows are some practical guidelines based on these discussions and on the treatment and social support literature. We hope that they will be of use to family, friends, caregivers, and loved ones who are searching for what to say (or, what not to say) to an individual struggling with an eating disorder.
Practical Guidelines for Support Providers:
1. Foster self-acceptance. Many individuals with eating disorders feel shame and guilt about their disorder. Learning that eating disorders develop for a reason (i.e., to cope with difficult emotions, to enhance self-esteem) can help support providers convey to their loved ones that recovery is difficult, and that change takes time. Patients have said that when their friends and families demonstrate understanding about the complexity of recovery, they feel more accepting of themselves and may be more willing to considertreatment.
2. Be curious and listen. It is easy to make assumptions about the experiences of others, such as oversimplifying a problem or presuming to know how someone else is feeling. Eating disorder patients describe this as particularly unhelpful. One way to avoid making assumptions is to express curiosity by asking open-ended questions, showing interest in your loved-one’s experiences, and enquiring about how she has coped with external pressures to change. Listening and expressing a genuine desire to help may assist her in developing a better understanding of herself and her eating disorder. This also sets the stage for a productive discussion aimed at determining what changes, if any, she wants to make.
3. Find support. If there is a possibility that your loved one is at medical risk, encourage her to seek outside help. This can be a challenging subject to broach; therefore, your stance and tone are critical. Clearly explain that although you understand that she may not want to recover or get treatment, you are genuinely concerned about her health and well-being. Provide this rationale: in order for you, as a supportive ally, to be most helpful (or at least to stop worrying/nagging), you need to know that someone else (preferably an experienced health-care provider) will step in if medically necessary. Seek support for yourself, perhaps through counseling or a support group, to help reduce your own distress and increase your ability to listen and maintain a collaborative stance.
4. Focus on your relationship. Support providers often focus on eating disorder symptoms. Patients report this as unproductive, and potentially damagingto their recovery. Individuals with eating disorders are already overly focused on their shape, weight, and eating. Shifting away from appearance-related values, toward building relationships and fostering personal development, has been shown to increase motivation for change. Thus, helping her reconnect with, or discover, positive characteristics about herself and her relationships may be helpful.
Individuals with eating disorders also have a tendency to isolate. Let her know she is welcome to participate in social events, and try not be critical if she declines, as this may further diminish her self-esteem. Also, be aware that talking about your own diet/weight concerns likely increases or maintains her appearance concerns and reinforces this value system.
5. Acknowledge and accept that your loved one is responsible for change.When a friend or family member expresses ambivalence about making changes or engaging in treatment, it is common for support providers to feel responsible for initiating this change and trying to “fix the problem” at all costs. Unfortunately, this subtle (or not so subtle) influence can be detrimental, as your loved one may perceive this as a threat to her sense of control. This may, in turn, damage your relationship and decrease the likelihood that your loved-one will engage in treatment.In fact, research has shown that individuals who engage in recovery for others are more likely to relapse after treatment. To be most helpful, try to respect your friend or family member’s limits—there may be some changes that she is ready for, and others that she is not.
- Grisset, N.I. & Norvell, N.K. (1992). Journal of Consulting and Clinical Psychology,60, 293-299.
- Tiller, J.M., Sloane, G., Schmidt, U., Troop, N., Power, M., & Treasure, J.L. (1997).International Journal of Eating Disorders, 21, 31-38.
- Treasure, J.J., Gavan, K., Todd, G., & Schmidt, U. (2003). European Eating Disorders Review, 11, 25-37.
By Krista E. Brown, BA, & Josie Geller, PhD
Reprinted with permission from Eating Disorders Recovery Today
Fall 2005 Volume 3, Number 4
©2005 Gürze Books
About the Authors
Krista E. Brown, BA, is a research coordinator at the St. Paul’s Hospital Eating Disorders Program, and a Group Facilitator at the Richmond Eating Disorders Program.
Josie Geller, PhD, is the Director of Research at the St. Paul’s Hospital Eating Disorders Program and an Associate Professor at the University of British Columbia.