Information about the stages of treatment

The cycle of change in eating disorder treatment

The cycle of change is used in many areas of psychology to help patients and their carers (whether family or not) understand that there are certain key stages in the treatment process.

It is extremely helpful for you, the carers, to understand how your interactions with your loved ones will differ depending on the stage of change.

The further your loved one moves from stage to stage, the better able they will be to respond positively to your efforts to guide and support them in making the changes needed. If you rush ahead before your loved one is ready, tension and possibly a breakdown in communication are likely.

As carers, you can only make assumptions about where your loved one is in the cycle of change. If you are overly optimistic about how far they have come, you will soon notice resistance to the help you offer.

The golden rule here is to go back to an earlier stage if in doubt, until you feel connected with your loved one again.

It is also interesting that you yourselves move through a similar cycle as you try to help. Unless it is completely clear to you that you are in the “Action” stage, you may not yet have had the chance to change your own behaviours. Remember that even the smallest change in a carer's behaviour can make a difference for their loved one.

Example:  Takis is 15 years old and at the  “Contemplation” stage of changing his eating disorder behaviours. He says he might be able to add one or two foods to his list of safe foods. His father focuses on the following encouraging words: “OK, Takis, I can see you're thinking about making changes and I'll tell you what I think we should do. I'm here to help you.” Takis may feel intense pressure and go back to his safety behaviours (here, his particular list of foods), so as to feel in control again.

A slightly different response from his father might be more motivating: “Takis, I can see you're thinking about making some changes. Help me understand the benefits you get from staying as you are, and what would make you feel that some small changes might be possible. I'm here to help.”

Information about the stages of the Model of Change

This model describes the process a person needs to go through to achieve lasting change. It is a tool we use in eating disorders.

1. “Pre-contemplation” stage

The person with the ED (Eating Disorder) does not see that there is a problem (lack of insight), or sees that there is a problem but does not intend to change it.

They may believe it is not something that needs to change, or rationalise it in their mind: “I'm just really stressed at school lately, I eat fine, honestly!” They may genuinely be puzzled by your concerns and feel threatened by your efforts to change them, to “take away” the eating disorder / to “fix” them, when they don't have “any problem”.

In addition, the person with the ED may have experienced other stages of the cycle of change in the past and believe that any treatment will be inadequate because previous treatment interventions failed. The “Pre-contemplation” stage can be persistent and difficult to overcome. 

2. “Contemplation” stage

The person with the ED understands that there is a problem, but is still ambivalent about change.

Part of them wants to change, but another part resists. Perhaps change doesn't seem that attractive, or they don't feel able to succeed. They often say one thing (“I'll eat”) and do another (they don't manage to eat when their plate is put in front of them).

3. Preparation stage

The person has decided to change and starts making plans. This can be a fragile stage. Fear of failure may creep in and prevent the person from moving on to the “Action” stage.

4. Action stage

The person has started making changes. This stage presents many difficulties for the person, and progress is more likely to be achieved through careful implementation of small, specific, achievable changes rather than big leaps.

5. Maintenance stage

The person with the ED has started to stick with what they have decided and to resist relapse. Self-confidence grows as success continues.

“Relapse”

It may be a momentary relapse or one of longer duration and intensity, but it is always an opportunity for learning!

Relapse and returning to an earlier stage of the cycle can happen at any time, and all of this is part of the necessary process of change.

Moving from one stage to the next is not a smooth, straight line. A person may move from one stage to another again and again, back and forth and forward again. Someone may be firmly in “Action” in one part of their recovery, but at the “Pre-contemplation” stage regarding another (e.g. sticking firmly to their meal plan, but not seeing why they should reduce their excessive exercise).

So the process may look like a tangled ball of string, where the person with the ED moves from one stage to another, back and forth and round and round…

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The tangled lines show how frequent the ups and downs are in the recovery process.

Staying patient and learning from relapses and mistakes is important. Carers often struggle, because people with an ED cannot appreciate how much effort this takes.

Many people have later said in their treatment: “I may not have shown that I noticed the support my carers gave me, and I know my parents felt their efforts were wasted… I couldn't respond then, but I heard every single thing they said to me.”

1. The “Pre-contemplation” stage – For the carer

Carers often express frustration at not knowing what to say when their loved one with an ED simply looks at them blankly. 

There are many options here:

Try to connect with your loved one, talk about topics other than the eating disorder, spend time with them

Try to separate the person from the eating disorder

Try not to fall into the reassurance trap. Encourage the person to look for evidence or the logical answer themselves

Always try to look after yourself. Keep up your interests  and  your routine, and encourage the rest of the family to do the same.

Give information about their health – Calmly point out the eating disorder and its effects (e.g. the person feels cold, can't concentrate, etc.)

Give information from leaflets about the effects of eating on health

Try to avoid:

• Arguing or criticism! These make it harder for the person to talk about their worries.
• At the “Pre-contemplation” stage, any argument for change from the carer will probably lead to more resistance from the person and louder voices telling them to stay as they are.
• Giving advice when it isn't wanted
• Not direct advice – but indirect: “What would you say to a friend who told you this?” “This book says…” etc.
• Don't let the ED “take over” the family! This is not easy, and the family will need to pull together around the goal. It's not just one person's job!

Remember that your loved one is suffering from an illness and that the eating disorder serves a purpose for them (“I feel safe, in control, the disorder is my only friend, it understands me, etc.”)

Sometimes, as a carer, you will need to step in and take charge of the situation for a short time, but always look for the opportunity to step back and give your loved one more and more responsibility to regain healthy control.

Useful phrases for Carers when the Patient is at the Pre-contemplation Stage

• It must be confusing for you to think that we, your parents, are worrying unnecessarily
• It must be upsetting when people who see you keep commenting on your health
• How would you describe your life right now?
• How are you feeling? You seem to have been in a bad mood lately..
• Tell me about things that make you feel good
• I've noticed you're struggling and I'd really like to help you. What do you need? How can I help?
• I've noticed you feel very cold and look very tired.
• If you had a magic wand, what would your life be like?
• You're clever and creative and I'd be interested to hear your opinion about ….

At this stage, your loved one is likely to be particularly sensitive to criticism and even to the hint of negative comments. That is why it is important to stay calm and kindly ask how they see things in their life.

Speak to them positively and remind them to look at the bigger picture in life, not just the details.

2. The “Contemplation” stage

Here your loved one understands that there is a problem, but may still be ambivalent about making changes. Part of them WANTS to change and another part doesn't.

Perhaps the desire for change is not yet strong, or they don't believe in their ability to change. They may say one thing (“I'll eat”) and do another (not eat). It is hard for the carer not to rush to say something like “but you said you'd eat, why aren't you?” 

Even if you say it calmly, your loved one, who is struggling to eat at that moment, may take it as a critical remark. The struggle becomes harder and the voice of the disorder grows louder: “DON'T EAT THAT. IT WILL MAKE YOU VERY, VERY FAT. ONLY I UNDERSTAND YOU. LISTEN TO ME”

What we suggest for carers at the “Contemplation” stage

• Encourage your loved one to talk about the disorder and what it does to them. They may feel safe enough with you to explore the effects of the disorder.
• Help them make a list of the pros and cons of change, both for themselves and for others
• Point out the link between the eating disorder and its effects
• Discuss the downsides of change in detail: what would be difficult? Would they like to think of alternative strategies? What are they afraid of?
• Discuss possible action plans

Try to avoid:

• Arguments in favour of change while your loved one is still torn and most likely leaning towards rejecting change

The following exercise is a very helpful tool for this stage:

1.    In favour of ChangeQuestion: What does the disorder give you right now?	2.    Against ChangeQuestion: What downsides of the disorder can you think of right now?
4.            In favour of ChangeQuestion: In your opinion, what could be good about letting go of the disorder?	3.            Against ChangeQuestion: Help me understand what might be making it hard for you. Do you see anything negative about making changes?

 This exploration contains ideas for open questions that carers can use to open the conversation about the possibility of change. As their loved one begins to consider this possibility, their thoughts move from one to the next, as shown in the square above. It is easy for carers to forget square 3 and rush to square 4 while the patient is not yet ready.

By following the numbering of the square, carers have a good tool for understanding their loved one's inner dialogue as they move from the Pre-contemplation stage to Contemplation and then on to Preparation.

 Carers can even guess what the patient would say in each part of the square before talking with them. This can help them better understand the difficulty the patient is experiencing and, above all, how the voice of the disorder that troubles them “speaks”.

Square 3 “shows” how much the voice tells them they will lose if they let go of the disorder (control, safety, attention, the friendship of the disorder), as well as the terror at the thought that they might not succeed (“what if I can't make the changes?”). There is also the big question: “who will I be if I no longer have my disorder?”

As long as the carer can show interest in and understanding of these thoughts, the patient feels better understood and able to rely on the help of their loved ones. With patience and in their own time, the patient will make their moves.

Useful phrases for carers here:

• I've read that the eating disorder makes you feel you gain things. I'd never thought of that. Help me understand what it gives you
• I can see that if I had something that gave me so many benefits (feeling safe, in control, having a friend with me), I'd find it hard to give up. There would have to be some significant downsides for me to do it. When I think of it like that, I can understand how hard it is.
• Can you describe any downsides you see with the eating disorder? Is there a small part of you that would like to get rid of it?
• I feel as though you're thinking a little about making some changes and, at the same time, the thought makes you anxious. Would you like to talk about the difficulties you're facing?
• I'm impressed that you're starting to think about the possibility of making some changes
• I can see it's hard for you to think of reasons to make changes right now. Let's go for a walk and talk, if you like.

3. The Preparation stage

At this stage, the patient has begun to think more and more in favour of change and of leaving the eating disorder behind. Now conversations are needed about how the changes can happen, step by step.

Carers can try:

• Can I help you in any way?
• Would you like us to make a plan for how to achieve one specific change?
• Is there anything I do that doesn't help you? What is it?
• What will success look like with the next change? What exactly will happen?
• How can they “measure” the change? How will they know it's working?
• Who can help you with this change?
• What difficulties might come up?

Try to avoid:

• Belittling or ignoring the patient's willingness to talk about change and its difficulties.

Here carers can use Solution-Focused Questions:

1. What exactly would you like to be different?
2. What exactly can you do to get started?
3. If it starts well, what will come next?
4. who could help, and what exactly could you ask them for?
5. What might be the signs that your change is going well?
6. What would you do if things didn't go so well?

This strategy helps strengthen the patient's strengths. Carers have nothing to lose and much to gain by putting the patient in the position of adviser on their own issues.

 It is important that changes happen in small steps and are noticed. Carers observe the changes and every success is acknowledged.

4. The Action stage

As the patient starts strategies to manage weight/vomiting/binge eating, etc., they are at the same time trying to manage many complex emotions. The physical and psychological changes of recovery can be very difficult to cope with.

Encouraging and supporting the patient helps build self-confidence and self-management. The patient learns to “answer back” to the voice of the disorder.

What is recommended for carers:

• Offer your help in managing emotions and urges to return to old habits
• Support in problem-solving, especially in relation to the eating disorder
• Talk about what the patient has learnt from previous relapses
• Make a list of signs that may lead to relapse
• Listen to their fears
• Help them set smaller goals in order to achieve bigger ones
• Set clear boundaries
• Encourage independence
• Discuss whether they have noticed benefits from the changes they are already making

Try to avoid:

• Phrases that don't show you appreciate how much “work” they are putting into their changes
• Talk with them about all the strengths in their character (kindness, creativity, passion, sensitivity, hard work, etc.)

4. The Maintenance stage

It is very important for carers to realise that their loved one who reaches this stage still needs a lot of support and understanding.

They may still feel frightened, alone and weak, and this can give the voice of the disorder the chance to grow stronger.

“I've reached the weight I agreed with my nutritionist, now I also eat on my own at home, I study for my exams and I play tennis. On the surface I may look fine, but inside I'm boiling! All the emotions and fears that had been covered up by my disorder are now coming back out and overwhelming me.

Fortunately, my parents are always there to support me. I can talk to them about every difficulty. They don't criticise me when I fail and they encourage me to keep trying. They help me get back on my feet every time someone at school comments on my body. They help me understand that sometimes other people don't know what I've been through, and that's why they make such comments.”

At this phase, the patient keeps up the action and resists relapse. The voice of the disorder lurks somewhere in the background and may sometimes reappear. Carers need to be patient and stay calm throughout this period.

Suggestions for carers at the Maintenance stage:

• Help avoid relapse – keep a list of the warning signs of relapse
• If a relapse happens, treat it as part of recovery, not as a disaster
• Offer support and understanding
• Discuss techniques for managing situations
• Encourage their independence and talk about their goals for the future
• Keep rewarding healthy behaviours and successes

Try to avoid:

• A critical attitude and aggression

Learning from Relapses

Relapses are part of the recovery process.

It is very useful to discuss strategies for managing them, because the patient may experience disappointment and despair. Appropriate encouragement and support from carers can help the patient keep building their self-confidence and take more and more control of their life.

Advice for carers:

• If a relapse happens, treat it as part of recovery.
• Support the patient with understanding
• Remind them of past successes
• Help them break down the achievement of their goals into small steps

Try to avoid:

• Critical comments, expressions of disappointment, disapproval. 

The information given here aims to show carers how they can properly support their loved ones in the recovery process. A key element is the willingness and ability to understand sincerely.

Being in step with the patient is also important: the carer follows the patient at their own pace. They don't push, don't get disappointed, don't belittle. It is worth noting down below your own observations, ideas and strategies that you see helping you and your loved one in their recovery.

You know them well and, even if you don't always do everything right, this person sees and appreciates everything you do for them.