WHO DO WE THINK THEY ARE? -confronting myths in the treatment of eating disorder
Kjersti Gulliksen & Johanna Levallius NEDS Helsinki 2016
Who do we think they are? Who do they think they are? Who do they want us to be? Who can they become?
Placebo
External factors
Patient
Therapist
Method
Part 1
WHO DO WE THINK THEY ARE?
Part 2
WHO DO THEY THINK THEY ARE?
Anorexia Nervosa: The Patients’ Perspective Project associates: Ragnfrid H. S. Nordbø,Phd Ester M.S. Espeset, PhD Kjersti S. Gulliksen, PhD Josie Geller, Associate professor Finn Skårderud, Prof.dr.med Arne Holte, Prof.dr.philos, Project coordination: Norwegian Institute of Public Health Modum Bad Research Institute Financed by: The Research Council of Norway, Norwegian Foundation for Health and Rehabilitation
Methods Empirical,phenomenological research design with elements of grounded theory 41 participants with Anorexia Nervosa (DSMIV) Data gathered in two steps Descriptive, phenomenologacally oriented papers Theory building papers (grounded theory)
Gulliksen (2014) ”Anorexia Nervosa: Patients’ Perspective of Pathways to AN, Wish to recover, First treatment Contact….”
4 Pathways to AN Precursors Triggers Reinforcers Awareness of Self-determination Gulliksen et al., ”Four pathways to anorexia nervosa. Patients’ perspective on the emergence of AN. In press
4 Pathways to AN The Avoidant The Achiever The Transformer The Punisher Gulliksen et al ”Four pathways to anorexia nervosa. Patients’ perspective on the emergence of AN. In press
Conclusion Pathways to AN
The eating disorder symptoms may result from a variety of subjective psychological dynamics
Gulliksen et al., ”Four pathways to anorexia nervosa. Patients’ perspective on the emergence of AN. In press
PERSONALITY 2 PROFILES Tatja AN à EDNOS restrictive Pia BN
Tatja
80
Women
Tatja
70
60
50
40
30
20
10
N
E
O
A
C
Pia
80
Women
Pia
70
60
50
40
30
20
10
N
E
O
A
C
FIVE FACTOR MODEL
NEUROTICISM
EXTRAVERSION
OPENNESS
AGREEABLENESS
CONSCIENTIOUSNESS
CONSCIENTIOUSNESS
Competence
Order
Dutifulness
Achivement Striving
SelfDiscipline
Deliberation
RELEVANCE 1. 2. 3. 4.
HEALTH, SUCCESS & HAPPINESS ED & PD TREATMENT PROGNOSIS
Ozer & Benet-Martinez 2006; Andersen & Bienvenu 2011; Widiger & Presnall 2013; Martinez & Craighead, 2015; Högdahl et al 2016; Haynos et al 2016; Levallius et al (in press)
Illness process: personality and mechanisms. Ferguson 2013
Part 3
WHO DO THEY WANT US TO BE?
Preferred therapist characteristics Findings from interviews
(Gulliksen et al 2012)
Acceptance
Generosity
Vitality
Challenge
Active interest
Focus on resources
Humor
Challenge difficulties
Respect
Patience
Disregard Passivity Predjudice
Pampering
Expertise
Experienced knowledge
Authoritativeness
ACCEPTANCE VITALITY CHALLENGE EXPERTISE
Art of balance
Part 4
WHO CAN THEY BECOME?
MYTH?
’SYMPTOMS à PERSONALITY’
HARD EVIDENCE 1 Risk Personality P change à S change
Hirschfeld et al 1989; Greenop et al 2009; Andrews 2010; Chow & Roberts 2014
MYTH?
’PERSONALITY IS SET LIKE A PLASTER’
Roberts, Walton, Viechtbauer 2006
Society/ Environment System/ Family Psychological
Personality Genetic
Molecular
Agreeableness
Roos & Kajonius (in prep)
STARTER KIT ’I’m able to’
’I expect you to’
’I want to’
’just do it!’
CHANGE
Bleidorn 2012; Hennecke et al 2014; Roberts & Jackson 2008
HARD EVIDENCE 2
CHANGE AFTER THERAPY
The study 209 adults BN/EDNOS 2 treatments 3*240 1 year
Levallius et al (in prep)
28% reliably changed/trait
Levallius et al (in prep)
Does trait matter? Does outcome matter?
4
1 year change in personality
d = 0.55 d = 0.58
3 2 1 0 -1 -2 -3 change still ill
-4 -5 -6
N
E
O
change recovered
A
C
SO WHAT?
MEANING OF CHANGE
Specific Structural
Personality change
Structural change ’Patients show greater emotional stability, joy, openness to experiences, trust in others, belief in their capability & increased selfdiscipline’ = à secure attachment
Levallius et al (in prep); Noftle & Shaver 2006
THE PATIENT’S WISH TO RECOVER
What may trigger the patient’s wish to recover? •
Sense of Vitality – Joy, consentration, spontaneity and energy
•
Sense of Autonomy – Self-determination, choose to recover, new strategies of mastery
•
Sense of insight – Awareness, seeing nuances, limitation of goals, self-knowledge
•
Negative consequences – Loss of future, costs to own children, feeling sick or thin, social costs, physical costs. Nordbø et al., (2008) IJED
Motivation Reflects an interaction between the patient and contextual factors? Reflects the quality of relationships?
Increase or decrease in motivation Reflects the unique quality of the relationship between the patient and therapist, combined with other contextual factors in the patients’ life?
Who do we think they are? Who do they think they are? Who do they want us to be? Who can they become?
Placebo
External factors
Patient
Therapist
Method
Placebo
Patient
External factors
Therapist
Method
State/trait debate 35 30
Neuroticism
25 20 15 10 5
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
Time
Ormel et al 2012; Roberts 2009
Ormel et al 2012; Roberts 2009
State/trait debate 35 30
Neuroticism
25 20 15 10 5
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
Time
Ormel et al 2012; Roberts 2009
Ormel et al 2012; Roberts 2009
Treatment Joint case formulation (Allen, 2016) Ethics Meta-perspective
(Allen et al 2016)
80
70
60
50
40
30
20
10
Tatja
Tatja start
Tatja 1 year
80 70 60 50 40 30 20 10
Pia
Pia start
Pia 1 year
80 70 60 50 40 30 20 10
Pia
Pia start
Pia 1 year
4 WAYS à CHANGE 1. Implicit/explicit contingencies 2. Observation/imitation 3. Self-reflecion 4. Creation of meaning
Caspi & Roberts 2001
Research “Innovation points out paths that are possible; replication points out paths that are likely; progress relies on both” (Science 2015;349 p6251)
OS Collaboration 2015
Take home message:
’FOR EVERY COMPLICATED QUESTION THERE IS A SIMPLE ANSWER – WHICH IS WRONG’
