Clinical Psychology and Psychotherapy, Vol.

4 (3), 186191 (1997)

Stages and Processes of Change in Eating Disorders: Implications for Therapy

Anna Freud Centre, Maresfield Gardens, London NW3, UK Eating Disorders Research Unit, Institute of Psychiatry, DeCrespigny Park, London SE5 8AF, UK
2

Wendy Blake 1 , Sue Turnbull 2 and Janet Treasure 2

1

The aim of this study was to examine the trans-theoretical model of change in 51 anorexia nervosa and 58 bulimia nervosa patients attending a specialist clinic. Self-report questionnaires were completed as to the stage of change, decisional balance, and processes of change before initial assessment. Of the BN patients 80% were in a stage of action compared to only half of the AN patients. There was a shift in decisional balance between the stages of change. The strong principle of change was supported in that the pros of change were increased by over 1 standard deviation from precontemplation to action. The weak principle of change was not supported as there was less shift in the cons. Few processes were used in precontemplation, self re-evaluation was increased in contemplation and self liberation in action. The transtheoretical model of change appears to be applicable to patients with eating disorders. These preliminary findings suggest ways in which therapy can be targeted to maximize the level of motivation and to promote change itself. # 1997 John Wiley & Sons, Ltd.
Clin Psychol Psychother 4, 186191, 1997. No. of Figures: 1. No. of Tables: 3. No. of References: 27.

INTRODUCTION
The difficulties in treating women with eating disorders have been described at length (Bruch, 1973; Brownell and Foreyt, 1986; Alexander and Lumsden, 1994). One of the major hurdles is that patients with anorexia nervosa do not regard themselves as having a problem. This was a feature gue (1873), noted in the historical descriptions. Lase quoted one of his patients who said, `I do not suffer, therefore I must be well'. This denial or lack of insight is part of the ambivalence that these patients have about change. In the addictions understanding and tackling ambivalence is an important part of treatment
Correspondence to: Dr Janet Treasure, Eating Disorders Research Unit, Institute of Psychiatry, DeCrespigny Park, London SE5 8AF, UK. Tel: 44 171 919 3180. Fax: 44 171 919 3182. E-mail: spjejjt@iop.bpmf.ac.uk.

(Miller and Rollnick, 1991; Bennett, 1993). Sincoff (1990), when describing approachavoidance tendencies of a behavioural cognitive and affective nature, summarizes the subject's ambivalence as an inability to make important life decisions. Janis and Mann (1977) argue that resolution of decisional conflict comes about when losses derived from behaviour exceed gains, thus encouraging the individual to seek new solutions to chronic problems. Abelson and Levi (1985) suggested that decisional conflict can be alleviated when the reluctant decision-maker is able to determine when the information is relevant, and subsequently integrates it in such a way that a decision can then be made. The notion that people change their behaviour by progressing through various motivational stages has been influential in the addiction literature (Tuchfield, 1976; Kanfer and Grimm, 1980). The trans-theoretical stages of change model seems to

CCC 10633995/97/03018606$17.50 # 1997 John Wiley & Sons, Ltd.

Change in Eating Disorders offer a comprehensive and coherent view of this process. The key assumptions of the model are firstly, that to change behaviour, people move through a sequence of changes and, secondly, different processes of change are emphasized during different stages and encourage a progression through the stages (Sutton, 1996). The stages of change can be described in terms of a revolving door metaphor (Prochaska and DiClemente, 1992). The person entering the circle of change is in the stage of precontemplation (not thinking about change seriously). This is followed by the next stage in the model, contemplation (starting to think seriously about changing behaviour). The contemplation stage is followed by action (making an attempt to stop the behaviour). The action stage is followed by the maintenance stage (prolonged cessation of behaviour). Relapse may typically occur several times whilst cycling through the earlier stages before achieving long-term maintenance. Individuals can cycle through the stages several times before achieving long-term maintenance (Prochaska and DiClemente, 1992). Prochaska and DiClemente (1992) have recently added preparation as a stage between contemplation and action. However, the questionnaires available for the present study did not include this stage as it was a pre-treatment sample. The stages of change are strongly associated with a particular balance between the pros and cons of a behaviour, the so-called decisional balance (Prochaska, 1994). The second core dimension of the model is the process of change. Prochaska and DiClemente

187 (1983) identified 10 basic processes. These could be described as covert or overt activities that predominate and are integral to the individual's stage of recovery as they move through the stages of change. Whereas the stages refer to when particular shifts in attitude and behaviour take place, processes attempt to tap into how these shifts occur. The key hypothesis of Stages of Change model is that different processes, such as consciousnessraising or self-liberation, will predominate at different stages. Figure 1 shows that during the cycle of change the particular processes of change are emphasized (created from Prochaska et al., 1992). This may have implications of clinical relevance in providing the appropriate focus of treatment for individuals in particular stages (Prochaska and DiClemente, 1992). A self-treatment book based upon this model of change has recently been produced (Prochaska et al., 1994). Initially, the Stages of Change model was applied to the cessation of smoking (Prochaska and DiClemente, 1983; Prochaska et al., 1985, 1988). Subsequently, the model was applied to alcohol and drug abuse, weight control, safe sex and sunscreens (Prochaska et al., 1994). Recently, the Stages of Change model has been applied in the field of eating disorders (Ward et al., 1996). The results of this small-scale study with inpatients at the severe end of the eating disorder spectrum indicate that the trans-theoretical model might also be relevant for eating disorders. The aim of the present study was to examine whether the Stages of Change model is relevant to

Figure 1. Processes of change. P/C, precontemplation; C, contemplation; A, action; M, maintenance

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Clinical Psychology and Psychotherapy, Vol. 4(3), 186191 (1997)

188 a broader group, comprising eating disorder outpatients.

W. Blake, S. Turnbull and J. Treasure change from a series of mutually exclusive questions. The eating disorders version used in this study was adapted from Rossi et al. (1995). The Decisional Balance Inventory for Eating Disorders (DBI-ED) was a 20-item version adapted from Rossi et al. (1995). Statements were scored using a Likert scale scoring from 15, indicating a range of replies from `not at all important', to `extremely important'. Items represent gains or losses for self, gains or losses for significant others, self-approval or self-disapproval, and approval or disapproval of others. Processes of change were measured using the Processes of Change questionnaire (PSQ) for weight control (Rossi et al., 1995) adapted for use with eating disorders. This yielded a 48-item instrument in which eight of the 10 original processes used by Prochaska et al. (1988) were deemed relevant. Definitions of the various subscales are as follows (Prochaska et al., 1992): (1) Consciousness raising: increasing information about self and problem. (2) Dramatic relief: experiencing and expressing feelings about one's problems and solutions. (3) Self-re-evaluation: assessing how one feels and thinks about oneself with respect to a problem. (4) Self-liberation: choosing and commitment to act or belief in ability to change. (5) Reinforcement management: rewarding one's self or being rewarded by others for making changes. (6) Counter-conditioning: substituting alternatives for problem behaviours. (7) Helping relationships: being open and trusting about problems with someone who cares. (8) Stimulus control: avoiding or countering stimuli that elicit problem behaviours. The statements were scored using a Likert scale from 15 ranging in reply from `not at all' to `extremely'. A `not applicable' option was attached to some of the anorexic participants' questions, which were then not scored. Questionnaires are available from authors on request.

METHOD
Subjects
All participants were patients from the south-east of England referred to a specialist unit at the Maudsley Hospital in London (this is a secondary or tertiary service). The majority of patients had previous treatment from their primary care physician or from their community mental health service or from local eating disorder services. The diagnosis was made by a specialist consultant psychiatrist using structured clinical interviews using criteria from the DSM IV: 307.1 AN, 307.51 BN. Concurrent diagnoses were made using the Clinical Interview Schedule (CIS) a computerized, validated method of determining psychopathology (Lewis et al., 1988). Altogether, 117 questionnaires were collected. Of these three were from patients for whom no diagnosis was made, two were from obese bingers, and three were not completed sufficiently to be included. Of the 109 patients whose questionnaires were included in the analysis, two were from males and 107 from females. The age ranges were from 1660 years for participants with a mean of 27 years. Altogether, 51 (47%) participants were diagnosed as having anorexia nervosa (AN) (53%) (33 binge purge subtype; 18 restricting subtype) and 58 as having bulimia nervosa (BN). The duration of illness was shorter in the anorexia patients (mean, 8 years; range 120 years); bulimia nervosa (mean 13.8 years; range, 227 years). Comorbidity was common: bulimia nervosa (23% depression, 45% anxiety disorder, 4% OCD); anorexia nervosa purging subtype (50% depression, 4% OCD; 50% anxiety); anorexia nervosa restricting subtype (33% depression, 25% OCD, 25% anxiety).

Procedure
Prior to their assessment each of the participants was asked to complete three questionnaires: a Stages of Change algorithm, a Decisional Balance questionnaire and a Processes of Change questionnaire.

Statistical Analysis
Data were analysed using SPSS for Windows version 6.0 (Norusis, 1993). t-Tests were used to test for group differences in demographic data. A chi-square was used to test for differences in distribution of stages of change and multivariate analyses of variance (MANOVAs) with Bonferroni
# 1997 John Wiley & Sons, Ltd.

Questionnaires
The Stages of Change algorithm is a discrete categorical measure which ascertains the stage of

Clinical Psychology and Psychotherapy, Vol. 4(3), 186191 (1997)

Change in Eating Disorders corrections were used to look at differences between groups on processes of change.

189

Decisional Balance Inventory

Table 2 shows the mean scores of the pros and cons according to the stage of change (anorexia and bulimia nervosa are shown together as the pattern is similar). There was a shift in the decisional balance between the stages, the ratio of pros to cons being: precontemplation 0.82, contemplation 1.3, and action 1.4. These results, in part, support the strong principle of change as there is an increase in the pros of change from precontemplation to action of over 1 standard deviation. However, there is less shift in the cons between the stages.

RESULTS
Stages of Change
Table 1 shows the distribution of each diagnosis to the stages of change. No patients were in the maintenance stage of change and this stage is not considered in the analyses. The distribution across the stages of change were significantly different between the groups chi2 15X4, df 1, p 0X00009. The vast majority of the bulimia nervosa patients were in the action stage whereas the anorexia nervosa patients were more evenly distributed across the stages with half in the precontemplation and contemplation stages.
Table 1. Percentage of those in each stage of change Anorexia nervosa n 51 Precontemplation Contemplation Action 12 (23.5%) 14 (27.4%) 25 (49.0%) Bulimia nervosa n 58 2 (3.4%) 8 (13.8%) 48 (82.8%)

Processes of Change
The mean (SEM) scores for the processes are shown by stages of change for all eating disorders together in Table 3. All processes were lower in those in the precontemplation stage. There were significant differences on multivariate analysis of variance between stages on self-liberation and self-re-evaluation. Follow-up t-tests showed that self-liberation was significantly lower in precontemplation than in action t 2X03 p ` 0X05. Selfre-evaluation was significantly lower in precontemplation than in contemplation t 2X34 p ` 0X05 and action t 3X07 p ` 0X005.

Chi2 15X6, df 2, p ` 0X0005.

Table 2. The pros and cons of change from the Decisional Balance Inventory related to the stages of change Stage M and SD Pros M SD Cons M SD Table 3. PC n 14 24.2 7.2 28.6 10.5 Contemplation n 23 33.3 8.9 25.5 9.8 Action n 72 36.8 8.0 26.3 8.6 t-test contrasts PC ` C, Ac

no significant differences

Processes and stages of change Precontemplation n 14 Mean (SD) Contemplation n 23 Mean (SD) 2.77 2.36 2.57 2.23 1.67 3.20 3.58 1.95 (1.11) (0.95) (1.08) (1.15) (1.03) (0.89) (0.90) (0.86) Action n 72 Mean (SD) 2.50 2.74 2.78 2.60 1.68 3.15 3.80 1.67 (1.14) (0.89) (1.18) (0.92) (0.90) (1.28) (0.89) (0.69)

F-value F F F F F F F F 0X75 3X14 1X53 1X64 1X27 2X04 7X11 1X37

p-value p 0X48 p ` 0X05 p 0X22 p 0X20 p 0X28 p 0X14 p ` 0X001 p 0X26

Consciousness raising Self-liberation Dramatic relief Counter conditioning Stimulus control Helping relationships Self-re-evaluation Reinforcement management

2.31 2.19 2.21 2.25 1.27 2.46 2.75 1.76

(0.87) (0.77) (0.80) (0.89) (0.45) (1.37) (1.23) (0.53)

Multivariate analysis of variance, F 2X22, p ` 0X01.

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Clinical Psychology and Psychotherapy, Vol. 4(3), 186191 (1997)

190

W. Blake, S. Turnbull and J. Treasure is consistent across many behaviours. Between contemplation and action the pros are increased by 1 standard deviation and the cons decreased by 0.5 standard deviation (these have been called the strong and weak principles respectively). This finding has been replicated in another culture using a different theoretical framework and a different operationalization (Dijkstra et al., 1996). However, results of this study do not support the weak principles of change. This may be because of a difference in the instruments or it may be because the behaviours relating to eating disorders lead to slimness which is highly valued in our society. As has been found in other conditions precontemplation is associated with fewer change processes. Self-re-evaluation was increased in those in contemplation and self-liberation in the action stage. This is similar to the generic model (Prochaska and DiClement, 1992). Prochaska and DiClemente (1992) define the trans-theoretical approach to therapeutic integration as the differential application of the processes of change, at specific stages of change, according to the identified problem level. This approach has been applied to smokers and it has been found that an individualized trans-theoretical approach performed well (Prochaska and DiClemente, 1992). The problem of poor compliance and high drop-outs has bedevilled investigations into the efficacy of treatment for eating disorders, a trans-theoretical approach may limit this problem. We have applied the trans-theoretical model to a treatment approach for eating disorders (Schmidt and Treasure, 1997). Techniques to build upon the processes of consciousness raising, dramatic relief, self-re-evaluation and self-liberation are used in the initial stages of therapy. A motivational interviewing style is used to resolve the conflict relating to the pros and cons of the illness. Our pilot data suggests that this is a useful approach. There are limitations to the findings from this study. It was cross-sectional and involved small numbers in comparison with those in studies from which the model was derived. The questionnaires used had to be adapted for this patient group. Our aim will be to obtain longitudinal measurements with a larger patient group.

DISCUSSION
The study sprang from a need to understand more about ambivalence in patients with eating disorders and the way in which therapeutic interventions might be targeted to maximize the level of motivation to promote change in eating behaviours. The patient group is similar to the samples seen at most specialist centres in that they have a long duration of illness, a history of unsuccessful interventions and a high level of co-morbidity. Several interesting points of clinical relevance have emerged. Anorexic patients and bulimic patients were in different stages when they presented for treatment. The bulimic patients were most likely to be in action whereas more patients with anorexia nervosa were found to be in precontemplation and contemplation. We found that half of those with anorexia nervosa were not ready to change their behaviour when first presenting to the clinic. It is reasonable to speculate that this might be due to the more obvious nature of anorexia which might determine that people often come to the clinic at the suggestion of relatives or general medical practitioners, but they themselves may not be ready for change. More than 80% of the bulimics were initially motivated. The duration of bulimia nervosa is greater than that of anorexia nervosa and the secretive nature of the problem might determine that by the time people presented for treatment they were already trying to change their behaviour, although still wishing to exert control over their weight. The clinical features of anorexia nervosa are egosyntonic whereas this is not true in bulimia nervosa where the loss of control over eating is a source of great distress. On the other hand patients with bulimia nervosa are reluctant to give up their methods of weight control. It might have been interesting to repeat the application of the transtheoretical model with weight control rather than bulimia nervosa as the focus of change. We would predict that fewer cases of bulimia nervosa would be in action if this were the case. Transition between the stages was associated with a change in the ratio of pros and cons: those in action had more `pros' for change than those in precontemplation. Prochaska and DiClemente (1992) have emphasized that the shifting balance between pros and cons is important for those in the contemplation stage. This appears to be the case in eating disorders as the crossover of the ratio of pros and cons happens between precontemplation and contemplation. Prochaska (1994) observed that the pattern in the balance between the pros and cons of change

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Change in Eating Disorders

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