The myth of motivation

Such was the title of the talk given at the 2010 International Conference on Eating Disorders by British clinician Glenn Waller. Dr. Waller had a fascinating talk and, even when I didn't agree with him, I always thought he had a really good point.

In his talk, Dr. Waller looked at the difficult issue of patient motivation in eating disorders. It's a thorny and fascinating issue to many in the field because people with eating disorders often struggle with staying motivated for treatment. This is inherent to the nature of eating disorders: the denial of a problem (or the inability to see that there is a problem). It's one of the reasons eating disorders are so damned hard to treat.

When my illness first started picking up speed in college, I seriously had no clue that there was anything wrong. I was exercising more! I was losing weight! I felt great! What could be wrong? How could this be an illness? Easy: when you're not eating because you're scared of food, and you're health is starting to suffer. Ultimately, the downsides of an eating disorder become more apparent, and the idea is for a therapist to use these downsides to help patients make behavioral change.

The problem is that motivation is often, as Dr. Waller calls it, a manifesto statement: it's what we want to do, rather than what we intend to do (or are capable of doing). He compared these motivation-oriented statements to campaign promises--they don't really mean much until they're followed by action. This follow-through is where people with eating disorders really struggle, much like politicians.

Dr. Waller's response to this was rather eye-opening. He told therapists to stop being a part of the problem in maintaining poor motivation for change by buying into the motivation manifesto. By doing this, the therapist is trusting the anorexia, not the patient. "The anorexia can only be trusted to try to survive," Dr. Waller said, and motivation to attend/be in treatment doesn't equal motivation to change.

The main factor for me was anxiety and fear about changing my behaviors. I was often tired of the eating disorder but unable to push through the anxiety that was keeping my ritualistic behaviors in place. Thus the status quo remained in place. My other issue was that this fear was coupled by my minimizing the issues that my AN behaviors created. They weren't that bad, I could handle it, most people were on a diet- how was my life different? So how could I be motivated to work on a problem that I often wasn't even sure I had?

Researchers often talk about issues related to patient drop-out and premature treatment termination in people with eating disorders. What astounds me is not so much how many people drop out but how and why so many people stick with it. Dr. Waller didn't really address the issue of outside support, and I wish he would have. I found that I couldn't conquer my ED without someone temporarily stepping in and helping me start eating and gaining weight. I needed to have no other option but recovery--and then I was able to slowly start stepping up to the (dinner) plate and taking charge of my recovery.

The issue of motivation is still very relevant to me, even though I'm rather far along in recovery. Dr. Waller said that motivation work needs to continue throughout therapy as a person can be motivated to address certain issues and not others. Furthermore, motivation can wane or disappear entirely, so it's not something that can be addressed in the first session and then checked off.

There were lots of other bits of Dr. Waller's talk that I didn't agree with, such as his belief that patients who don't change are choosing to stay ill. It often looks like that, but the situation is more complicated. Many times, it wasn't as much that I was choosing to stay ill as much as it was that I didn't have adequate support to change. Yet I'm glad Dr. Waller addressed the issue of motivation, and how therapists can better help people move towards ongoing recovery.

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marcella said...

Fascinating report Carrie - thanks for attending and writing about it. This was one of the talks I would have gone to had I been able to go to Salzburg as I enjoyed Dr Waller's talk at EDIC and was intrigued by the title.

One thing that did strike me about Waller's talk at EDIC though, in marked contrast to at least one of the talks deliberately set up to challenge his ideas, was the lack of any mention of "life outside therapy". It would seem that he didn't have much to say about the client's other support mechanisms (ie the people who live with him or her 24/7 rather than just see him/her for 50 minutes a week) here either.

I'm very glad that clinicians such as Waller are out there developing and delivering evidence based treatments that really do work but I wonder whether services attempting to deliver evidence based care to a wider population than just those who "choose" to attend and are "motivated" to change (and have independent transport and a coordinated enough lifestyle to actually get to the appointments) can justify not looking to drawing in a wider support mechanism for their clients.

Cathy (UK) said...

Thanks as ever for this post Carrie...

You write:

"The main factor for me was anxiety and fear about changing my behaviors. I was often tired of the eating disorder but unable to push through the anxiety that was keeping my ritualistic behaviors in place".

My response to that is "Ditto". Anxiety was the number one deterrent for my recovery for many years. My anxiety was mainly linked to my feeling that I couldn't survive the world (especially the social world). Remaining engrossed in my anorexic rituals kept me occupied and it was an 'excuse'.

It was difficult to feel motivated to continue to eat (and hence to gain weight) when I was overwhelmed by anxiety. I didn't eat and gain weight to do all the social things that people tell you recovery will bring you - like having social competence and self confidence. Rather, I ate because I had already had so many 'near misses' with death and I felt so physically ill. I was tired of feeling 'crap' and scared of dying.

Like you Carrie, I don't believe that patients choose to remain ill. Most don't want to stay sick; they're just terrified of what recovery might mean for them; the overwhelming anxiety associated with behavioural change; and, whether mental recovery (not just weight gain) really does happen.

James Clayton said...

Some really interesting thoughts and I find myself going "yeah, that's me" with a lot of stuff. Also, Dr Waller's "The anorexia can only be trusted to try to survive" is also a really powerful truth.

Sustained motivation is vital but not easy when you've got anorexic intuition arguing against it. Thanks for yet another resonant post!

Anonymous said...

I read this post and the "no other option" post. I think what's hard is that for a lot of us chronic adults, we don't have outside help. I don't have parents or anyone to help me or cook for - I'm on my own, with children to tend to. I was easily outpriced for a nutritionist and it's not covered by insurance. Once a week therapy is barely helpful. What do adults do when there really is no outside help? It's hard to be motivated and not get obsessed even more when one is the only one in charge of cooking and when there is no time off to focus on recovery. It seems an endless battle, and one hard to stay motivated for.

Anonymous said...

Imagine you are a parent. You and your kid are standing on the ledge of a burning high rise building. The fire department has a safety net waiting for you to jump into, but your kid is extremely afraid of heights (as many people are) and cannot force herself to jump to save her life. As a parent, you wouldn't engage in talk therapy to try to overcome her fear of heights. Instead, you would lovingly grab her hand, temporarily think for her, and you would jump to safety, taking her with you. She might not have been "motivated" to jump on her own, but as a parent you can be motivated for her, by not giving her the choice not to be motivated.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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nour·ish: (v); to sustain with food or nutriment; supply with what is necessary for life, health, and growth; to cherish, foster, keep alive; to strengthen, build up, or promote


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