The eating disorder risk that female athletes face is intuitive and counter-intuitive at the same…
Motivation, Denial and the Stages of Change
By Deborah V. Gross, MD, Psychiatrist at The Ranch Mississippi
“This is ridiculous. It’s not a problem. I only purge when I get really stressed. I have to have something….” That was Belinda on her first visit to my office. When she passed out at her best friend’s wedding from dehydration due to laxative abuse, her family insisted she see me. Belinda’s ex-husband was attending the wedding with his new girlfriend and Belinda was worried how she’d look in her dress.
Belinda didn’t come back after the first session because she didn’t believe she had a problem. She acknowledged binge eating and purging with laxatives and said she’d been doing it since she was a teenager. However, she considered this to be “something a lot of people do.”
A year later, after two more fainting spells, Belinda’s family told her she had two choices. She could either get help on an outpatient basis immediately or they would seek involuntary treatment for her in a hospital. Belinda came back to see me and entered group therapy. After a little waffling, she admitted she was really tired of being controlled by her eating “issues.” She still didn’t want to call it a disorder, but she did want a new way of living.
Moving Past Denial
A big problem with conditions like eating disorders and addictions is that your healthy “real self” knows what you need, but that part of you isn’t in charge when you’re active in destructive behaviors. Therapists sometimes like to say, “The best predictor of future behavior is past behavior.” You could interpret that as, “Oh, well. That means I can’t change,” and give up. Belinda’s story illustrates another possibility. She finally realized, with a little push from her family, that she needed to make some changes and she couldn’t do it alone.
How did Belinda go from absolutely refusing to consider anything might be wrong to calling me for another appointment? She moved to a more advanced “stage of change.” Belinda was ready to admit she needed help. She was also ready to get help and use it—powerful stuff! Belinda was in the “action” stage of change.
The Stages of Change
For a long time, behavioral health specialists assumed motivation was something you either had or you didn’t; people with eating disorders or addictions either wanted recovery or didn’t want it. Nothing about humans is ever that simple.
In the 1990s, after two decades of research, James O. Prochaska and Wayne F. Velicer came up with what they called The Transtheoretical Model for changing behaviors. Later, in the hands of James Prochaska and Carlo DiClemente, this became the five-stage model of behavior change we use today. We usually call it “stages of change” for short, but the model is actually a way of gauging and describing someone’s level of motivation for making a specific change.
When I first saw Belinda, she was in the precontemplation stage of change. In the year between our visits, she progressed to the action stage. Here are brief descriptions of these and the other stages of change:
You don’t think about changing anything and may not even realize there’s a problem.
You start to see that there’s a problem. You might think about changes you want to make and consider pros and cons of doing so. For example, in this stage you might read a blog like this one, look at books online or think about calling a therapist.
You definitely plan to take action soon and may start taking small steps toward change. You might buy a book or ask your doctor for the names of therapists.
This stage is just what it sounds like—action. You’re taking steps, making specific, obvious changes. You might be going to meetings. You might be in drug or alcohol rehab. Change is in progress.
You have made changes, and the changes are stable. You are now working actively to prevent relapse. You are living in your recovery. For example, in the maintenance stage, you may attend Alcoholics Anonymous meetings and meet with your sponsor regularly, but only see your therapist as needed. People stay in this stage indefinitely.
You have zero temptation and 100% belief that you will maintain your changes no matter what. Not too many people with chronic (by definition) or compulsive (because of the necessity to continue the daily structure) disorders live here.
Relapse is not a stage of change. However, it happens with any chronic medical problem and it’s common any time we try to change our behavior patterns. The simplest definition of relapse is that it’s the process of going backward from one stage of change to an earlier one (but that’s a topic for another day).
How Denial Impacts Motivation
Motivation is not something you either have or you don’t. It’s not a “black-or-white” or “yes-or-no” kind of thing. Motivation can fluctuate for many reasons, such as:
- Type of illness
- Stage or severity of illness
- Other medical or emotional problems
- Other stresses in people’s lives
On top of that, eating disorders and addictions already have a “built in” motivation problem as a defining feature. It’s called denial. Denial is a primary symptom of these disorders.
A quick definition of denial is: the state of believing and acting as if something obviously true (to others) is false. For example, in Belinda’s case, if she denied (didn’t believe) that she had an eating disorder, she wouldn’t see any need to get help for it.
Denial isn’t about dishonesty. People in denial literally cannot see the reality of the problem. It’s part of the illness. Denial is how people with anorexia nervosa can literally die from starvation while believing they’re fat. It’s how people with alcohol use disorders can die from alcohol-related liver disease while insisting alcohol abuse isn’t the problem.
I’m often asked if involuntary treatment can work, and yes, it can if people are in treatment long enough for their brains to clear out some of the denial. Like motivation, denial exists on a continuum and can fluctuate over time. People can be very motivated to change at first, especially if they’ve had something bad happen like a DUI, but they sometimes lose motivation as time goes along. In the example of Belinda, motivation was external at first—her family gave her an ultimatum—but she became increasingly motivated with treatment.
There are also other change motivators. For instance, many women are more motivated to make healthy changes when they are pregnant or nursing a baby. To make things even more interesting, people can be at different stages of change for different aspects of their illness. For example, women with bulimia nervosa are often more motivated to deal with binge eating before they’re ready to deal with purging.
Why You Should Care About Stages of Change
Motivation issues lie at the heart of successful recovery from anything. Real recovery isn’t just words. Action is essential. It’s about what you do. People who successfully live a program of recovery do exactly that—they live it. That’s why people in recovery talk about taking it day by day and step by step.
You learn to live inside your recovery by doing your daily recovery work routinely, with an almost rhythmical structure. Some days you won’t feel like doing it. Some days you flat out won’t want to do it. Whether we’re talking about eating disorder recovery or addiction recovery, that’s a big “so what.” It doesn’t matter. You don’t have to like it, you don’t have to feel like it and you don’t have to want to do it. You just have to do it. There are very few absolutes in this world, but one of them is that if you want something to change, you have to change something, and that means doing the work, regardless of how you feel.
© Adapted from Dr. Gross’s forthcoming book, 90 Ways in 90 Days: A Personal Workshop for Women with Disordered Eating