Assessing readiness to change binge eating and compensatory behaviors
Introduction
Treatment refusal, noncompliance, and dropout are common in the treatment of bulimia nervosa (BN). Moreover, psychological treatment for BN has been found to lead to full remission in only approximately half of individuals who complete treatment Keel & Mitchell, 1997, Peterson & Mitchell, 1999. Recently, it has been suggested that therapeutic alliance and the interaction between eating disordered patients and therapists can have a profound effect on treatment success Kaplan et al., 2001, Treasure et al., 1999, Treasure & Schmidt, 1999, Wilson et al., 2000. It has also been suggested that matching therapist behavior and patient readiness to change may allow for better tailoring of treatment to individual needs (Geller & Drab, 1999).
Readiness to change refers to the degree to which an individual is motivated to change problematic behaviors and implies a willingness, or behavioral readiness, to initiate behavior change (Carey, Purnine, Maisto, & Carey, 1999). One model of motivational readiness that has received empirical support is the transtheoretical model of behavior change. The transtheoretical model suggests that change is an intentional process that involves continual movement and motivation towards action (Prochaska, DiClemente, & Norcross, 1992). Readiness to change is embodied in the levels of the model's core construct, the stages of change (Rossi, Rossi, Velicer, & Prochaska, 1995).
According to the most popular version of this model there are four stages of change, which reflect varying degrees of readiness to modify a problem behavior: precontemplation, contemplation, action, and maintenance. Individuals in the precontemplation stage do not think that they have a problem. They are not considering changing their behaviors and thus rarely present for treatment unless pressured to do so by others. Those in the contemplation stage have some awareness of their problem and may be considering changing their behavior at some point in the future, but are currently not taking steps towards action. This stage is characterized by a period of ambivalence about change, thus the individual might remain in this stage for an extended period of time. Those in the action stage are actively attempting to modify their behavior. It is likely that individuals in this stage are experiencing symptoms and thus are expending a significant amount of time and energy toward altering their behaviors, experiences, or environment to overcome their problem. The final stage is maintenance. During this stage, an individual must work hard to prevent relapse, as it is often easier to produce change than to maintain it.
One of the main contributions of this model is that it views change as a continuous process and highlights the need to assess the individual's readiness to change to determine the most appropriate intervention. It is hypothesized that if the intervention and readiness to change do not match, damage will be done to the therapeutic alliance, resulting in treatment failure Miller & Rollnick, 1991, Prochaska et al., 1992. For example, if an individual has not yet acknowledged that he/she has a problem or is unmotivated to change his/her behavior, it is inappropriate for a therapist to focus on strategies for behavior change.
The transtheoretical model has been widely applied to health promotion, where it is often employed to assist health-related behavior change by classifying people into different stages and then providing them with the appropriate stage-based intervention. Although much of the initial research on this model used smoking as the problem behavior, it has been applied to a variety of health behaviors, including alcohol and drug use, gambling, exercise, use of sunscreen, condom use, weight loss, and obesity DiClemente & Prochaska, 1998, Prochaska et al., 1994, Prochaska et al., 1992, Prochaska et al., 1994.
Recently, research has been conducted to examine whether the transtheoretical model of change is applicable to individuals with BN. Blake, Turnbull, and Treasure (1997) examined the applicability of transtheoretical model in anorexic and BN inpatients. Results indicated that 83% of the individuals with BN were in action compared to only 49% of those with anorexia. The authors speculated that the higher rate of BN individuals in action might stem from them endorsing action for reducing binging behaviors, but not for reducing compensatory weight control methods. Thus, they might be differentially motivated to change their weight control practices compared with their binging behavior. Ultimately, the authors conclude that the transtheoretical model could be a useful approach for addressing problems of poor compliance and treatment dropout that negatively affect the efficacy of treatment for patients with eating disorders.
Franko (1997) also suggested that readiness to change might be an important variable to consider in treatment for BN. She assessed readiness to change as a possible prognostic indicator for group cognitive behavioral therapy for 16 women with BN. The sample was split into two groups: those considered to be in contemplation and those considered to be in action. Results indicated that a greater proportion of individuals in action experienced a reduction in the frequency of binging during the course of therapy when compared to the contemplators. She concluded that assessing readiness to change before determining a treatment plan would allow clinicians to match patients to treatment modalities in the most cost-effective and time-efficient way possible.
In a more recent study of 125 BN women, Treasure et al. (1999) found that all of the BN individuals who were in action at pretreatment made a clinically significant reduction in their binge eating compared to 55% of those in contemplation. However, this finding was not true for compensatory weight control methods. The authors hypothesized that this was reflective of the use of a nonspecific stage of change measure, which asked about the individual's motivation to give up her “eating disorder.” They concluded that existing measures of stage of change may not be sophisticated enough to tap motivation for each of the behaviors associated with BN, and stated that future studies might improve the applicability of these measures to BN sufferers by separating binge eating and weight-control practices.
Concerns about the assessment of readiness to change in individuals with eating disorders have been echoed by many Geller & Drab, 1999, Kaplan et al., 2001, Reiger et al., 2000, Sullivan & Terris, 2001. Generally, stage and readiness to change are measured either by a categorization algorithm that assigns the individual to a discrete stage based on his/her responses to a series of four of five questions, or via a multiple-scale questionnaire, which provides scale scores on dimensions corresponding to the stages of change (Joseph, Breslin, & Skinner, 1999). The University of Rhode Island Change Assessment Scale (URICA; McConnaughy, DiClemente, Prochaska, & Velicer (1989)) is one of the most widely used multiple-scale questionnaires in the area of eating disorders. The URICA was originally developed for use with clients in psychotherapy, but its generic format has allowed it to be modified for use in many populations (e.g., smoking, alcohol, cocaine, exercise, weight control, sun exposure). Unlike a staging algorithm that assigns an individual to a discrete stage, the URICA results in a score on each Readiness to Change subscale, which allows for individuals to be engaging, to some degree, in multiple stages at the same time.
Nevertheless, it has been suggested that using the URICA, or other generic measures, to assess readiness to change is problematic because it is difficult to ascertain what symptom an individual has in mind when they complete a questionnaire that asks about their desire to change their “eating disorder” or “eating problems” in general Treasure & Schmidt, 2001, Treasure et al., 1999. Because BN is a complex condition that involves a number of disturbed eating behaviors and attitudes, individuals could be referring to any number of problems when responding to generically worded items, rendering their answers uninterpretable (Rieger et al., 2000). For example, an individual could be answering questions about his/her readiness to lose weight, placing them mostly in action for reducing binge eating. However, a therapist looking at the survey might assume they are also ready to change their compensatory behaviors. Such a misunderstanding is unlikely to strengthen the therapeutic alliance or promote good treatment outcome.
In sum, the use of general measures for the assessment of the complex behaviors associated with BN may risk misclassifying and alienating clients rather than actually assisting in tailoring treatments to serve them better. Thus, the purpose of this study was to evaluate whether assessing motivation to change binge eating and compensatory behaviors separately would better describe concurrent symptomatology compared with a more general measure of readiness to change eating behaviors.
Section snippets
Participants
Participants included 175 undergraduate college students, 113 females (64.6%) and 62 males (35.4%). Participants ranged from 17 to 31 years old, with a mean age of 18.55 (S.D.=1.27). Participants were primarily Caucasian (59%), with Asian/Pacific Islander (33.5%), Hispanic/Latino (1.7%), African Americans (1.2%), and other (4.6%) comprising the rest of the sample. No participants indicated that they were of Native American descent.
Procedure and measures
Participants were recruited through the psychology undergraduate
Binging behaviors
Majority of participants (n=138; 79%) reported binging at Time 1. Concurrent validity of the general readiness to change eating behaviors measure (URICA) was compared with the specific readiness to change binging behaviors measure (BRTC) for those who reported engaging in binge eating at Time 1. Hierarchical multiple regression analysis was performed entering the URICA subscales at Step 1 and the BRTC subscales at Step 2. Results revealed that although the URICA accounted for a significant
Discussion
This investigation evaluated the validity of general versus specific readiness to change indices in predicting concurrent bulimic symptomatology in a sample of college students. Results revealed that assessing readiness to change binge eating and compensatory behaviors separately accounted for greater variance in BN-related behaviors than a more general measure of readiness to change “eating behaviors.” Results also provided discriminate validity for measuring readiness to change binge eating
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