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Psychological Dimension of Eating Disorders Pt.2


Winter 2004, Volume 3, Issue 1
Resistance, Motivation, and Change in Eating Disorders
Marian Eberly, RN, MSW, CISW, DAPA
Dena Cabrera, PsyD
A. David Wall, Ph.D.
Kari Wolfe, MS, CPC
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

“I do not understand what I do. For what I want to do I do not do, but what I hate I do… I have the desire to do what is good, but I cannot carry it out.” (Romans 7:15-16, 18)

"Brittany simply isn’t motivated," her therapist sighed. "I’ve tried everything I know, but she just won’t let go of her eating disorder."

"What about talking to her family?" replied the dietitian.

"Done that! She can’t seem to surrender her eating disorder. She just hasn’t hit bottom yet. I’m very worried about her; I think she needs inpatient treatment."

Brittany, a 19-year old freshman at a prestigious Midwestern college, was a 4.0 honor student in high school and active in cross country and track. She was always very thin, but her weight dropped dramatically shortly after she went to college. Cindy, Brittany’s residence hall counselor, was increasingly concerned. Brittany never showed up for meals and, if she wasn’t in the library studying, she was out running or in the gym.

Cindy took action after Brittany passed out in class. Brittany was taken to the emergency room, given IV fluids, and released. Cindy confronted Brittany the next day.

"Brittany, I want to talk to you about something. I am very concerned about you. I mean…," Cindy struggled for words. "What happened yesterday finally pushed me over the edge. I think you have anorexia!"

"What? Anorexia!" Brittany’s disbelieving response was mixed with surprise and anger. "Forget it, I’m fine." She stormed out.

Cindy consulted university administration and Brittany was told that without treatment she could not return to school. Her father upped the ante: "No more money for college until you get help."

Brittany resisted her inpatient treatment team. Fifty minute therapy sessions seemed like two hours. Brittany insisted she didn’t need help. She repeated: "How could my parents do this to me?" and "You are not going to make me fat." She remained aloof from the other women in treatment, except for those who shared her anger and denial. The others gave up on confronting her because she responded with sarcasm and anger to any challenge.

Eventually she began to talk about her life, feelings, stress level, and need to do everything perfectly. Risking vulnerability was new and frightening for Brittany; it required acknowledgment that something might be wrong–that she might be weak. Although Brittany made some progress, she frequently slipped back into defiance.

Brittany rated her motivation for recovery at 5 on a 10 point scale, but at 1 if recovery meant gaining weight. Her anger, stubbornness, and lack of motivation could try the patience of anyone. She seemed willing to go only so far and then dug her heels in.

So is Brittany simply unmotivated? Can this type of resistance be overcome?

In addressing eating disorders fully within the bio-psycho-social-spiritual model (Cumella, 2002), it is essential to consider the several aspects of the human psyche, including emotion, cognition, behavior, and will. The last—will—involves the capacity of human beings to make moral distinctions according to their value system and to choose moral, healthful, life-promoting behaviors—or the opposite (Wall & Eberly, 2002). Most professionals recognize that eating disorders are inherently life-compromising, because eating disorders constrict emotions and relationships and harm individuals physically. Yet those with eating disorders, like Brittany, often seem unable to choose recovery. For reasons that seem compelling to them, they choose instead the compromises and ravages of the eating disorder. This choice involves the human will.

The motivation to engage in eating disorder behaviors and these behaviors’ resistance to change are directly related to the depth and power of the need(s) that eating disorders fill. The greater the need(s), the stronger the motivation to stay sick. Because needs may wax and wane, eating disorder behaviors may also wax and wane. In our introductory example, Brittany’s resistance to change tells us that she is very motivated to engage in her eating disorder; the needs it fulfills must therefore be powerful.

In treating eating disorders, it is important to understand why patients may oppose treatment and health and choose illness instead. It is also essential to understand how to work with patients who are not committed to recovery, because such patients deserve competent treatment and access to effective interventions as much as those who are committed to recovery. By understanding the functions an eating disorder may be serving for specific individuals, and hence why they may be choosing eating disorder behaviors, it is possible for treatment providers to offer interventions that make sense to each individual—interventions that patients can actively choose and that will move them closer to recovery. “The wise heart will know the proper time and procedure… For there is a proper time and procedure for every matter” (Ecclesiastes 8:5-6).
Understanding Resistance

“Now there is in Jerusalem near the Sheep Gate a pool… Here a great number of disabled people used to lie–the blind, the lame, the paralyzed. One who was there had been an invalid for 38 years. When Jesus saw him lying there and learned that he had been in this condition for a long time, He asked him, ‘Do you want to get well?’” (John 5:2-7). Rather than jumping at the chance to heal, the man responded to Christ’s question with excuses and rationalizations for why he had never taken advantage of the healing waters in the pool. Like this man, some will suffer for long periods of time without availing themselves of the healing opportunities that are presented to them.

Resistance to treatment is common in treating eating disorders. It may occur for several reasons.

For patients with eating disorders, the power to control one’s life and health can be conceptualized in a distorted manner due to malnourishment. Therefore, biological factors should not be overlooked when creating a treatment plan for resistant patients. For patients experiencing significant cognitive disruption due to malnutrition, more purely behavioral interventions may be needed. Cognitively oriented therapies may be ineffective until a measure of nutrition restoration has been accomplished.

Biological dysfunction in the emotion regulation (limbic) system of the brain may also contribute to long-term resistance. Simply put, researchers hypothesize that brain physiology may accentuate emotional sensitivity in some people—leading them to respond too quickly, intensely, and enduringly to emotional triggers (e.g., Linehan, 2001). Such reactions typically elicit invalidating responses from other people, which reinforce the pattern of emotional dysregulation. Such patients clearly need significant focus on learning new emotion regulation skills or they will be motivated to continue their eating disorder behaviors in an effort to regulate emotions.

Due to the potential biological underpinnings of what treatment teams may label resistance, it should be clear that resistance is not always volitional. Patients may comply with treatment in many ways, be unable to improve despite their best efforts (Hamburg et al., 1989).

On the other hand, some patients do volitionally oppose treatment efforts. Some may refuse to participate for seemingly irrational reasons. Some feel threatened or afraid that in recovery they will not know how to meet basic needs or maintain an identity, so they resist as a self protective act. Some convince themselves that their symptoms are actually beneficial. Perhaps they feel powerless or helpless over their obsessions and compulsions and are attempting to reduce cognitive dissonance by believing that they have chosen or desire their symptoms. Such beliefs may offer the patient a sense of self-efficacy, mastery, and accomplishment (Yager, 1992). However distorted such beliefs may seem to those who treat resistant patients, it is important to understand these and similar underlying issues which may lead to secondary gain in resistant patients. We must intentionally utilize techniques in treatment that will not add to such resistance or contribute to a pattern of recalcitrance, but will instead lead to an understanding of the root causes of resistance and allow us to work with it effectively.

Whatever the causes, a pattern of enduring resistance, chronicity, and recalcitrance can be complicated by a countertransference response from the treatment team. Jesus’ response to the man at the pool had no trace of countertransference; it was not one of frustration or anger or indifference. Instead, Jesus responded with compassion and healed the man in spite of the man’s ambivalence about recovery.

Countertransference often manifests as provider frustration, compassion fatigue, and exhaustion, and may lead treatment providers to disengage from the patient and offer less effective or thorough care. Treatment providers can take safeguards against countertransference when working with chronic eating disorder patients.

1. Recognize what is good about the patient’s resistance: Reframing the resistance involves recognizing that all defenses serve a purpose. Seek the adaptive function. Sleuthing out the purpose can take time, but it is time well spent. Otherwise, providers may discover their treatment plans have become a revolving door.

2. Choose how you will respond to resistance: Resistance can be a powerful tool in the hands of a skilled clinician. It also has the potential to teach us about ourselves as people and practitioners. If you listen, resistance can teach you about the judgments you may habitually make and conclusions you unconsciously draw.

Sometimes persistent resistance may not be the patient’s problem, but instead a clinician skill issue. The clinician may be reinforcing resistant behavior without realizing it. "The more therapists confronted patients, the more resistance patients exhibited and the less behavior changes" (Patterson & Forgatch, 1985). Since dealing with resistance may be a slippery slope for many practitioners, it is important to know what not to do. Several ways to increase resistance in eating disorder patients include (Miller & Rollnick, 2002):

* Arguing for change
* Lecturing
* Assuming the expert role
* Shocking, criticizing, shaming, and blaming
* Labeling what the patient is rather than focusing on choices and behaviors
* Being in a hurry

Doing these things will result in a power struggle. But effective therapists help patients figure out how to control their own behaviors rather than attempting to control the patients themselves.

Success in working with resistance has its root in agreeing together with the patient on treatment goals. Stay focused on the goals, and when there is a deviation from them, name it. When behaviors impede the patient’s ability to accomplish her goals and create true change in her life, address them as treatment interfering behaviors.

It has often been asserted that people don’t change because they haven’t suffered enough or "hit bottom." But the humiliation, shame, guilt, and angst of hitting bottom are not the primary engines of change. Ironically, these usually immobilize people (Miller & Rollnick, 2002). Instead, people typically change when they connect with something of intrinsic value, something important or cherished.

A framework has been developed to help us better understand behavior change. Prochaska and DiClemente (1992) suggest that people pass through a series of stages as they change their behavior. This process has been appropriately called stages of change. The stages of change model includes six specific stages through which patients proceed, generally in this order:

* Pre-Contemplation - "I don’t need to change….. I don’t have a problem."
* Contemplation – "I know I need to change, but ….."
* Preparation – "I’ve decided to change."
* Action – "I am doing what is needed in order to change."
* Maintenance – "I am committed to my recovery lifestyle and prepared for relapse."
* Relapse – "I need to review what I need for change to occur."

Based on scientific research, the stages of change model unfolds in detail a principle of change delineated in Scripture: “I planted the seed, Apollos watered it, but God made it grow” (1 Corinthians 3: 6-7). In relation to truth, particularly the Gospel’s life-changing truth, the human soul begins as a barren field needing seed before it can spring to life (pre-contemplation). In offering life-changing knowledge, the health professional scatters good seed on the barren soil, offering the possibility of positive change (contemplation). By providing information and encouragement appropriate to each person’s stage in the process of change, the health professional then waters the seed, which may begin to sprout (preparation). Continued watering through stage-appropriate interventions assists the patient in taking the early and important steps toward change/recovery, allowing the sprouts to grow (action). In a personal relationship with Christ and through the action of the Holy Spirit, the individual develops into spiritual maturity/recovery (maintenance). Finally, all people–regardless of their stage of change or recovery–are vulnerable to relapse and need continual self-examination and restoration: “If we claim to be without sin, we deceive ourselves and the truth is not in us. If we confess our sins, he is faithful and just and will forgive us our sins and purify us from all unrighteousness” (1 John 1:8–10). The professional’s role in the relapse stage is to restore the patient gently (Galatians 6:1).

The ANSOCQ, or Anorexia Nervosa Stages of Change Questionnaire, has been found to be a strong predictor of weight gain in patients with anorexia (Rieger, et al., 2000), suggesting that the stages of change model has direct relevance to treating eating disorders. Other readiness for change research likewise suggests the utility of this approach with eating disorders (e.g., Cockell, 2000; Geller, Cockell, & Drab, 2001; Vitousek, Watson, & Wilson, 1998). At Remuda, we have found that the stages of change model can be an effective therapeutic tool as it can increase the patient’s awareness of her own process as she struggles with recovery. This structured approach reveals much to patients about their ambivalence and provides a framework for therapists to better understand ambivalence, resistance, and motivational issues. Geller (2002) found that clinicians tend to rate readiness to change higher than client’s actual readiness. Therefore, when clients state that they want to stop eating disorder behavior, one must be careful not to assume that they are fully ready to change. For example, a client may be quite motivated to stop bingeing and purging, but be unconcerned and unwilling to address her low body weight. It is essential to assess the stage of change for each symptom of an eating disorder rather than assume that patients’ motivation is uniform for their entire eating disorder (Geller & Drab, 1999). Addressing each at its differential level of motivation is essential for recovery to proceed. The stages of change perspective challenges us to look at each client individually, rather than to assume that every client is ready to change when entering treatment.

Precontemplation Stage. Some patients in this stage are in denial and not thinking about change. Others may be clearly aware and accepting that they have an eating disorder, but their attitude and behavior convey that they are unwilling or uninterested in change. Often patients feel that the consequences of the eating disorder have not become serious enough to warrant change.

In this stage, the eating disorder is ego-syntonic—the patient is comfortable with it and views it as consistent with her values and wishes. Therefore, the goal in this stage is simply for patients to begin thinking about change. Here, interviewing, assessment, and conceptualization are crucial.

Often therapists want to use action-oriented approaches, but these do not account for variances across patients in eating disorder symptoms or motivation. Interventions need to be tailored to patients’ specific characteristics and behaviors while keeping in mind the goal of the precontemplation stage—for patients to begin thinking about change.

It is valuable at this stage for therapists to take a stance of validation and acceptance. This includes teaching patients that they are accepted regardless of their behavior, identifying feelings, empathizing, and being nonjudgmental. Through this process, patients can begin to self-validate and avoid the recapitulation of guilt and shame. Further, by exploring patients’ value systems, therapists may find "a chink in the armor" and utilize it to create useful ambivalence. Creating cognitive dissonance can be powerful in motivating change. Thought provoking questions and assignments help with this process. Questions should consist of internal and external references. For example: If you were to decide to change, what do you imagine might be some advantages? What motivates others to change? Would life be better in any way if you stopped the eating disorder?

An assignment that helps patients to gain insight is to take stock of the emotional, social, and spiritual state they are experiencing at this time. Factual information about their medical condition can present a reality check. However, research demonstrates that shocking or trying to jar a patient into changing does not work. In truth, this is the best way to shut down the change process (Miller & Rollnick, 2002).

Precontemplators are most influenced by the eating disorder’s cons. These push them into contemplation (Reiger, Touyz, & Beaumont, 2002). Focusing on losses— physical, emotional, relational, spiritual, and so on—will make an impact in transition to the contemplation stage.

Contemplation Stage. In a recent study using the stages of change, the majority of inpatients with anorexia were assessed to be in the precontemplation or contemplation stage (Treasure & Schmidt, 2001). Overall, most patients with eating disorders are in the contemplation stage in the various domains of their eating disorder.

In the contemplation stage, patients recognize the devastating emotional, physical, social, and spiritual toll the eating disorder has taken. However, they are extremely ambivalent about whether or not to change their behavior. Patients are caught between the desire to stop and the fear of stopping, which creates psychic pain, even agony for some.

At this point, the professional’s goal is to assist patients in thinking through the risks of their behaviors and the potential benefits of change and to instill hope that change is possible. As the professional continues to accept, validate, and acknowledge the patients’ position, the ultimate goal is to help patients resolve their conflict/ ambivalence.

It is useful to ask thought-provoking questions, such as: What are the benefits and risks of the eating disorder? What concerns you most about stopping? What are the barriers today that keep you from changing? Why do you think you have an eating disorder? Behavioral interventions include visual aids to assist with identifying the pros and cons of the eating disorder. This helps to create imbalance so that the decision not to have the eating disorder becomes more desirable than the decision to have it. In this stage it can also be useful to consider future consequences. Assignments may include having patients write out what their life will be like in five years both with and without the eating disorder. This may provide tremendous insight into what the ambivalence is about for them.

A thorough behavioral analysis of the patient’s eating disorder may also be important in understanding the function of the eating disorder. This can help identify skills deficits, emotion regulation problems, and other barriers to change. We have found that often the underlying issue is maturity fears due to reinforcement of dependency by others and/or a lack of life skills. Because of this function of the eating disorder, treatment might focus on enhancing independent living skills.

It is also critical in the contemplation stage to focus on helping patients to build self-efficacy (Reiger, Touyz, & Beaumont, 2002). This creates hope and a belief in the patient that "I can really do this." As the pros for recovery increase and individuals develop hope, the likelihood of moving into the preparation stage increases.

ANSOCQ results suggest that the most change occurs between the contemplation and preparation stages (Reiger, Touyz, & Beaumont, 2002). The several methods described herein can facilitate this essential change and improve the chances for individuals’ recovery.

Preparation Stage. In this stage patients want to quit the eating disorder and begin to prepare emotionally, behaviorally, and physically for doing so. Counseling centers on “change talk”–desire, optimism, hope, advantages of change, and ultimately the intention to change. Patients have made the decision and are determined to recover but have not actually stopped the eating disorder; they are getting ready for behavioral change in the near future.

The goal of treatment in this stage is to help patients formulate a comprehensive plan for decreasing and ceasing their eating disorder behaviors, including identifying support systems, anticipating challenges, and devising ways to address challenges. Areas of intervention include educating the patient about body changes, imbalance, and weight issues, and addressing nutrition and exercise components. It is important to discuss the roles of family and friends in supporting and/or sabotaging success, to increase awareness of eating disorder triggers and to make plans about which skills will be used to counteract them. Assignments include having patients track changes and modified behaviors, reminding patients of the pros of eating disorder recovery, and encouraging patients to prepare a written commitment to their recovery and to make their commitment public. This helps with accountability and support. While focusing on these interventions, it is imperative to continue building patients’ hope and self-efficacy.

Action Stage. This stage requires a considerable commitment in time and energy to modify behavior, environment, and attitude. At this point patients have stopped the eating disorder and are implementing the plan for which they have been preparing. This may be a rewarding stage for the treatment provider, given that patients are motivated and are invested in the outcome of treatment. However, it is important not to equate patient action with recovery per se. With the stages of change model, relapse is a rule rather than an exception. At any time, patients may transition back to a previous stage with one or more symptoms of their eating disorder. Thus, professionals may find that they are working with patients who are simultaneously at different stages of recovery regarding various eating disorder symptoms.

Treatment during the action stage includes carefully listening and affirming that patients are doing the right thing. Praise and affirmation of success are valuable to patients’ self-efficacy as well as an inspiration for them to continue in the recovery process. In addition, family and peer encouragement can be very valuable.

It is essential during the action stage to continue teaching about, identifying, and exploring specific relapse triggers that patients have encountered and to discuss what patients did to cope with these triggers. Assignments involve having patients make a list of skills/tools they will need to utilize most given their individual triggers. Treatment at this stage can involve more experiential exercises, such as art therapy, restaurant eating challenges, and cooking assignments. Treatment also needs to address the grief and loss issues related to giving up the eating disorder. Thought provoking questions include: What do you fear will happen if you are successful? What are you going to miss most by not having an eating disorder? Sometimes these questions are overlooked by providers for fear that patients will relapse if these ideas are brought to the surface. But patients are thinking about and experiencing loss from the adjustments they are making. With careful intervention and support, assignments can safely and directly address patients’ grief and loss issues.

Other interventions at this stage will vary depending on patients’ diagnostic comorbidity, including Axis I and II disorders. Many times, as eating disorders subside or symptoms diminish, co-occurring symptoms will exacerbate because the stress of living without eating disorder behaviors may be frightening or difficult for patients. For example, as patients demonstrate recovery in their eating disorder, obsessive compulsive behaviors, impulsive behaviors, or depression may increase. Additional assessment may be needed at this juncture to determine which treatment protocols will assist patients with their co-occurring issues, including psychopharmacological interventions.

Maintenance Stage. In the maintenance stage, patients begin to identify themselves as someone who is “recovering” and in the practice of living without an eating disorder. Patients will occasionally want to engage in eating disorder behaviors, but will instead work on specific counter measures to cope with their urges and thoughts. The goal is to help patients gain personal insight and continue growing in recovery, focusing on quality of life issues.

Provoking probes to guide patients into this type of exploration include: Let's talk about the person you want to be, or, what are you doing to become more like that person? It is also necessary to discover and explore with patients new issues that may have appeared as they pursue recovery. Assignments and interventions might encourage patients to carry the message of recovery by sharing with others their recovery story. This reinforces their efforts and continues to imbue their pain and struggle with meaning and value through the act of helping others.

Relapse Stage. When in relapse, patients have moved backward in the recovery process, either in behaviors or in previous ways of thinking and feeling. In this stage, patients often experience an incredible amount of embarrassment, guilt, and shame. Patients may isolate and keep their relapse secret, which can hinder chances for re-entering recovery.

The goal at this stage is to process the relapse therapeutically and to help patients learn from what has happened. All the while, it is important to validate the patients’ pain about relapsing, and convey faith in their ability to move forward. This helps reduce their feelings of shame, imperative at this point in time. Another important objective is to help patients move as quickly as possible through the stages of change from which they regressed during relapse. Thus, reworking activities and assignments from previous stages is recommended. Additional assignments for patients may include having patients take inventory of the barriers to success and doing a thorough review of triggers and vulnerabilities. The frequency of therapeutic sessions should increase as well to maximize skill building.
Bottom Lines

“…snatch others from the fire and save them.” (Jude 1:23)

The question often arises about whether these motivational approaches can work with the cognitively impaired, severely malnourished, medically compromised patient. We have found that indeed they can and do. Even so, there have to be bottom lines when working with this specialized group of patients.

Bottom lines include state or family guardianship to maintain life and safety, sometimes resulting in involuntary treatment; patient transfer to a higher level of care, such as an inpatient treatment center, locked psychiatric facility, or closely monitored behavioral feeding program; force-feeding through mechanical means; and medical restraint.

Bottom lines communicate safety to the patient: "Here is the limit, this is as far as we go with this particular intervention, and here are the choices available to you now."

When discussing bottom lines it is crucial to maintain a non-punitive stance of compassion, reassurance, and understanding. Professionals working with clients can create an atmosphere of collaboration and negotiation, reframing the bottom line in the context of promoting the client’s health and safety. Obviously, individual autonomy should be promoted as much as possible by presenting the patient with choices and recommending the least restrictive bottom line possible. It is also helpful to maintain a position of advocacy, informing the client throughout the process of her rights and the options being considered to promote her health and safety. Finally, it helps to avoid surprising the patient with abrupt consequences; as bottom lines may potentially become necessary, it is useful to inform the patient of the natural course that treatment may need to take to protect her health and safety.

The goal and hope are that the refeeding accomplished through bottom line interventions will bring improved cognitive and emotional functioning, which will increase the client’s motivation for recovery and ability to participate in action-oriented treatments. Bottom lines, when effectively applied, can return the client to treatment more ready to engage and make therapeutic progress.

Cockell, S.J. (2000). A decisional balance measure of readiness for change in anorexia nervosa. Dissertation Abstracts International. (UMI No. NQ56661).

Cumella, E.J. (2002). Bio-psycho-social-spiritual: Completing the model. The Remuda Review: The Christian Journal of Eating Disorders, 1, 1-5.

Geller, J. (2002). Estimating readiness for change in anorexia nervosa: Comparing clients, clinicians, and research assessors. International Journal of Eating Disorders, 31, 251-260.

Geller, J., Cockell, S.J., & Drab, D.L. (2001). Assessing readiness for change in the eating disorders: The psychometric properties of the readiness and motivation interview. Psychological Assessment, 13, 189-198.

Geller, J., & Drab, D. L. (1999). The Readiness and motivation interview: A symptom-specific measure of readiness for change in the eating disorders. European Eating Disorders Review, 7, 259- 278.

Hamburg, P., Herzog, D.B., Brotman, A.W., et al. (1989). The treatment resistant eating disordered patient. Psychiatric Annals, 19, 494-499.

Linehan, M.M. (2001). Dialectical behavior therapy. In N.J. Smelser & P.B. Baltes (Eds.), International encyclopedia of the social and behavioral sciences (pp. 3631-3634). Oxford: Pergamon Press.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.

Patterson, G. R., & Forgatch, M. S. (1985). Therapist behavior as a determinant for client noncompliance: A paradox for the behavior modifier. Journal of Consulting and Clinical Psychology, 53, 846-851.

Prochaska, J. O., & DiClemente, C. C. (1992). The transtheoretical model of change. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 300-334). New York: Basic Books.

Rieger, E., Touyz, S., Schotte, D., Beaumont, P., Russell, J., Clarke, S., et al. (2000). Development of an instrument to assess readiness to recover in anorexia nervosa. International Journal of Eating Disorders, 28, 387-396.

Reiger, E., Touyz, S. W., Beaumont, P. J. (2002). The anorexia nervosa stages of change questionnaire (ANSOCQ): Information regarding its psychometric properties. International Journal of Eating Disorders, 32, 24-38.

Treasure, J. and Schmidt, U. (2001). Ready, willing, and able to change: Motivational aspects of the assessment and treatment of eating disorders. European Eating Disorders Review, 9, 4-18.

Vitousek, K.B., Watson, S., Wilson, G.T. (1998). Enhancing motivation for change in treatment resistant eating disorders. Clinical Psychology Review, 18, 391-420.

Wall, A.D., & Eberly, M. (2002). Five Biblical factors in eating disorder development. The Remuda Review: The Christian Journal of Eating Disorders, 1, 6-10.

Yager, J. (1992). Special problems in managing eating disorders. New York: American Psychiatric Press.
Challenge Course: An Experiential Learning Tool
David Woods, MBA
Division of Patient Care Services
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

Jesus taught them … by parables." (Mark 4:2)

A challenge course typically consists of a series of poles or trees connected by rope or cable. Participants accept challenges to cross a span or leap from one place to another. Activities often require teamwork. High ropes activities—20 feet or more in the air—include a zip line, rock climbing wall, trapeze jump, giant ladder, inclined balance beam, and others. During high ropes, participants are connected to a safety line and wear a harness and helmet. Low ropes activities— heights of 5 feet or less—include a horizontal obstacle course, trust fall, balance activities, and others. During low ropes, fellow participants and staff provide a "safety net".

Power of Metaphor. Challenge course activities involve metaphors, as did Jesus’ parables. For example, a patient might be asked: "If climbing this wall is recovery, where would you place yourself on it?" During Remuda’s challenge course experiences, patients are exposed metaphorically to Scriptural truths that will enable them to recover and live life effectively. Other examples:

* An elevated challenge course platform represents the safety of the eating disorder; a trapeze bar, an aspect of recovery. Patients may choose to leave the platform and jump into the air to catch the trapeze bar. In Matthew 8:22, Jesus talks about leaving what is dead behind in order to follow Him into life, and in Matthew 11:12 Jesus reminds us to pursue the kingdom of God without hesitation.
* On the challenge course zip line, patients travel rapidly through the air for 270 feet, attached to a cable and a safety line. This gives patients the metaphorical opportunity to leave part of their eating disorder behind without returning to the platform to take it back. This experience reflects Christ’s wisdom (Luke 9:62) about embracing the kingdom of God and never looking back.
* As patients begin climbing the challenge course rock wall, they are encouraged to evaluate their approach to achieving their goal. It is wise to get a boost from a teammate rather than to expend great energy merely to get started on the rock wall. In Luke 14:28, Jesus offers a parable about the importance of assessing one’s resources before beginning a task.

Multi-Channel Learning. In addition to their ability to teach through the power of metaphor, challenge courses are beneficial because they offer multi-channel learning—auditory, visual-nonverbal, and kinesthetic/tactile. Each individual learns differently. Not everyone learns best through traditional verbal therapy. Challenge course experiences offer a range of learning modalities that reinforce and supplement verbal therapeutic interventions.

As people approach a challenge course, they hear instruction and direction. They hear others’ comments about their experiences, concerns, and excitement. The challenge course is visually stimulating because it is often unfamiliar, even foreboding. The experience is full of visual cues and requires visual assessments. People touch, climb, hang on, let go, jump, and ride—a cornucopia of kinesthetic/tactile experiences. As such, challenge courses embody this wisdom: "Tell me and I will forget; show me and I may remember; involve me and I will understand."

Circumventing Familiar Defenses. Some patients have become adept at saying the right things in clinical settings, but have difficulty "walking the walk" or making real behavioral progress. Challenge courses are often unfamiliar; they invoke the common human fear of heights and therefore increase patients’ disequilibrium. In this situation, patients are off balance and cannot react with the typical defenses they erect in traditional therapy settings. They discover new possibilities.

Participants often find that they can do more than they thought. By experiencing and triumphing over the course’s challenges, they begin to look at life’s problems with a new perspective, knowing they can use problem-solving skills and feedback from peers to move forward. They practice effective communication skills to express needs and set boundaries. They have opportunities to increase trust as they participate in activities where their very physical safety involves other people. These applications allow individuals to discover more effective attitudes and behaviors specific to eating disorder recovery and adaptive living in general.

Remuda patients have been benefiting from challenge course lessons for the last four years. Patient comments and objective ratings indicate a significant benefit to their recovery.

Next Issue: Social Dimension of Eating Disorders

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