An Alternative Model of Eating Disorder Service Delivery Josie Geller, Suja Srikameswaran, Laird...
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An Alternative Model of Eating Disorder Service Delivery Josie Geller, Suja Srikameswaran, Laird Birmingham, Krista E Brown, Megan Jones, Jasmin Abizadeh St. Paul’s Hospital, University of British Columbia Introduction Discussion Menu of Treatment Options Traditional treatment models focus on early weight restoration and reduction of eating disorder behaviours. Unfortunately, these models have been associated with high rates of dropout and relapse. Restriction precontemplation, or the extent to which individuals want to restrict their dietary intake and lose or maintain a low weight has been shown to predict dropout and long term outcome (1,2). A readiness-based model of specialized care consists of a menu of outpatient and inpatient treatment options addressing readiness for change, skill development, quality of life, and medical safety for individuals who are not yet ready for symptom- reduction treatment. In this model, action-oriented treatment is offered only to those who are highly motivated to normalize their eating and work on weight restoration. Readiness-based treatment differs from traditional treatment in how it apportions clinical resources. In readiness-based treatment, an equal amount of resource is invested in preparing individuals for change as in assisting individuals in making changes. The figure below contrasts resource allocation in a traditional vs. readiness-based model. The purpose of this research is to evaluate the impact of a readiness-based model of specialized care. The preparation phase is associated with improvements in readiness. Significant reductions in ED and psychiatric symptoms occurred across all menu options. Dropout rates from residential or intensive treatments were very low. Readiness and Motivation scores predicted dropout from the Discovery program. A collaborative readiness-based service delivery model that provides a menu of outpatient treatment options prior to inpatient treatment may result in improved outcomes and less costly care. Further research is needed to understand how improvements in readiness occurred in the preparation phase. Please address correspondence to: [email protected] Preparation Phase Action Phase Readiness-based Model Preparation Phase Action /Maintenance Phase British Columbia Medical Services Foundation Traditional Model Preparation Phase Patient Education Group – Four-session didactic group on ED etiology, readiness, coping skills and social support. Contemplation Group – Six-session group to increase understanding of the function of the ED. Readiness and Motivation Therapy (RMT) – Five-session individual therapy on helpful support, ED functions, and higher values. Evaluation (n = 113). RCT results indicate that RMT is associated with significant improvements in readiness, and that individuals with the highest ambivalence are most responsive to this treatment. Medical Monitoring Clinic – Brief meetings with internist and nurse to review medical status and set nutritional goals. Voluntary Admissions to Specialized Unit – Three-week hospital admission for medical stabilization, renourishment and breaking ED symptom cycle. Pre-care Sessions – Several individual sessions offered prior to inpatient admission to establish treatment goals and review program guidelines. Readiness Program – Holds two groups and one meal support weekly to prepare patients for residential treatment by reviewing Discovery program expectations and providing opportunities to experiment with change. Evaluation (n = 103). Results from Continuous Quality Improvement (CQI) research indicate that individuals who complete Readiness experience improvements in eating disorder symptoms. Community Outreach Partnership Program – Outpatient program using harm reduction, psychosocial rehabilitation, and motivational intervention principles to improve quality of life for individuals with enduring eating disorders. Evaluation (n = 44). CQI Results indicate that individuals experience improvements in readiness and in bulimia symptoms. Baseline Restriction Precontemplation (Rest P) scores for entire sample = 68% Pre- Discovery Rest P scores = 50% Pre- Quest Rest P scores = 59% 0 Resource Allocation . Method References 0 10 20 30 40 50 60 70 80 R estriction Precontem plation Intake Q uest D iscovery 0 10 20 30 40 50 60 70 80 R estriction Precontem plation Com pleters Non-completers This figure compares readiness scores at intake and at the time of entry in the two Action Phase programs. This figure compares treatment completers and those who dropped out from Discovery on readiness scores. This finding is consistent with previous research. 0 2 4 6 8 10 12 14 16 18 20 D uration of illness (years) Intake Q uest D iscovery Duration of Illness by Program Predictors of Retention Discovery completers = 83% All patients referred to our service over the past five years (N = 628) completed study measures at intake, before and after each treatment menu option, and at 6-month follow-up. Readiness and Motivation Interview (RMI; 1, 3) measures readiness to change dietary restriction, bingeing, purging, and cognitive symptoms. Restriction precontemplation (Rest P) was used in this research. Brief Symptom Inventory (BSI; 4) assesses psychiatric symptoms. Depression, Anxiety, and Global Severity Index were used in this research. Eating Disorders Inventory – 2 (EDI-2; 5) measures eating disorder cognitions and behaviours. The drive for thinness, body dissatisfaction, and bulimia scales were used in this research. Quality of Life Inventory (QOLI; 6) assesses life satisfaction with 16 domains. Readiness by Program As shown in this figure, individuals assessed and treated at the EDP have been ill for a long time. Patients admitted to the Quest program have a particularly lengthy duration of illness. Action Phase Discovery/Vista Residential Treatment – 12 to 15 week emotion-focused, behaviour change group treatment program with residential component. Evaluation (n = 103). Significant improvements at post-treatment on all EDI subscales, all BSI scores, QOLI, and readiness for change. The majority of these changes were maintained at 6 month follow-up. Quest Inpatient/Outpatient Treatment – Intensive treatment program of variable duration for individuals who have not benefited from other action treatments. Evaluation (n = 43). Significant improvements at post-treatment on all EDI subscales, all BSI scores, QOLI, and readiness for change. Follow-up data collection is underway. Follow-up groups – Weekly outpatient groups for graduates of action phase treatments. Meal support – Supported meals are available on an as-needed basis to program graduates. Quest completers = 84% In Quest, early discharge was associated with more severe psychiatric symptomatology and higher drive for thinness at admission. 1. 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. 2. Geller, J., Drab-Hudson, D., Whisenhunt, B., & Srikameswaran, S. (2004). Readiness to change dietary restriction predicts outcomes in the eating disorders. Eating Disorders: The Journal of Treatment and Prevention,12, 209-224. 3. 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. 4. Derogatis, L. R. & Spencer, P. M. (1982). The brief symptom inventory (BSI): Administration, scoring, and procedures manual. Towson, MD: Clinical Psychometric Research. 5. Garner, D. (1991). Eating disorder inventory-2: Professional manual . Odessa, FL: Psychological Assessment Resources. 6. Frisch, M.B., Cornell, J., Villanueva, M., Retzlaff, P.J. (1992). Clinical validation of the Quality of Life Inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment, 4, 92-101.
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Transcript of An Alternative Model of Eating Disorder Service Delivery Josie Geller, Suja Srikameswaran, Laird...
An Alternative Model of Eating Disorder Service Delivery Josie Geller, Suja Srikameswaran, Laird Birmingham, Krista E Brown,
Megan Jones, Jasmin Abizadeh St. Paul’s Hospital, University of British Columbia
IntroductionIntroduction
DiscussionDiscussion
Menu of Treatment OptionsMenu of Treatment Options
Traditional treatment models focus on early weight restoration and reduction of eating disorder behaviours. Unfortunately, these models have been associated with high rates of dropout and relapse.
Restriction precontemplation, or the extent to which individuals want to restrict their dietary intake and lose or maintain a low weight has been shown to predict dropout and long term outcome (1,2).
A readiness-based model of specialized care consists of a menu of outpatient and inpatient treatment options addressing readiness for change, skill development, quality of life, and medical safety for individuals who are not yet ready for symptom-reduction treatment. In this model, action-oriented treatment is offered only to those who are highly motivated to normalize their eating and work on weight restoration.
Readiness-based treatment differs from traditional treatment in how it apportions clinical resources. In readiness-based treatment, an equal amount of resource is invested in preparing individuals for change as in assisting individuals in making changes. The figure below contrasts resource allocation in a traditional vs. readiness-based model.
The purpose of this research is to evaluate the impact of a readiness-based model of specialized care.
The preparation phase is associated with improvements in readiness. Significant reductions in ED and psychiatric symptoms occurred across all menu options. Dropout rates from residential or intensive treatments were very low. Readiness and Motivation scores predicted dropout from the Discovery program.
A collaborative readiness-based service delivery model that provides a menu of outpatient treatment options prior to inpatient treatment may result in improved outcomes and less costly care. Further research is needed to understand how improvements in readiness occurred in the preparation phase.
Please address correspondence to: [email protected]
Preparation Phase
Action Phase
Readiness-based Model
Preparation Phase
Action /Maintenance Phase
British Columbia Medical Services Foundation
Traditional Model
Preparation Phase Patient Education Group – Four-session didactic group on ED etiology, readiness, coping skills and social support.
Contemplation Group – Six-session group to increase understanding of the function of the ED.
Readiness and Motivation Therapy (RMT) – Five-session individual therapy on helpful support, ED functions, and higher values. Evaluation (n = 113). RCT results indicate that RMT is associated with significant improvements in readiness, and that individuals with the highest ambivalence are most responsive to this treatment.
Medical Monitoring Clinic – Brief meetings with internist and nurse to review medical status and set nutritional goals.
Voluntary Admissions to Specialized Unit – Three-week hospital admission for medical stabilization, renourishment and breaking ED symptom cycle.
Pre-care Sessions – Several individual sessions offered prior to inpatient admission to establish treatment goals and review program guidelines.
Readiness Program – Holds two groups and one meal support weekly to prepare patients for residential treatment by reviewing Discovery program expectations and providing opportunities to experiment with change. Evaluation (n = 103). Results from Continuous Quality Improvement (CQI) research indicate that individuals who complete Readiness experience improvements in eating disorder symptoms.
Community Outreach Partnership Program – Outpatient program using harm reduction, psychosocial rehabilitation, and motivational intervention principles to improve quality of life for individuals with enduring eating disorders. Evaluation (n = 44). CQI Results indicate that individuals experience improvements in readiness and in bulimia symptoms.
Baseline Restriction Precontemplation (Rest P) scores for entire sample = 68%
Pre- Discovery Rest P scores = 50% Pre- Quest Rest P scores = 59%
0
Resource AllocationResource Allocation
.
MethodMethod
ReferencesReferences
0
10
20
30
40
50
60
70
80
Restriction Precontemplation
Intake QuestDiscovery
0
10
20
30
40
50
60
70
80
Restriction Precontemplation
CompletersNon-completers
This figure compares readiness scores at intake and at the time of entry in the two Action Phase programs.
This figure compares treatment completers and those who dropped out from Discovery on readiness scores. This finding is consistent with previous research.
0
2
4
6
8
10
12
14
16
18
20
Duration of illness (years)
Intake QuestDiscovery
Duration of Illness by Program
Predictors of RetentionPredictors of Retention
Discovery completers = 83%
All patients referred to our service over the past five years (N = 628) completed study measures at intake, before and after each treatment menu option, and at 6-month follow-up. Readiness and Motivation Interview (RMI; 1, 3) measures readiness to change dietary restriction, bingeing, purging, and cognitive symptoms. Restriction precontemplation (Rest P) was used in this research. Brief Symptom Inventory (BSI; 4) assesses psychiatric symptoms. Depression, Anxiety, and Global Severity Index were used in this research. Eating Disorders Inventory – 2 (EDI-2; 5) measures eating disorder cognitions and behaviours. The drive for thinness, body dissatisfaction, and bulimia scales were used in this research. Quality of Life Inventory (QOLI; 6) assesses life satisfaction with 16 domains.
Readiness by Program
As shown in this figure, individuals assessed and treated at the EDP have been ill for a long time. Patients admitted to the Quest program have a particularly lengthy duration of illness.
Action Phase Discovery/Vista Residential Treatment – 12 to 15 week emotion-focused, behaviour change group treatment program with residential component. Evaluation (n = 103). Significant improvements at post-treatment on all EDI subscales, all BSI scores, QOLI, and readiness for change. The majority of these changes were maintained at 6 month follow-up.
Quest Inpatient/Outpatient Treatment – Intensive treatment program of variable duration for individuals who have not benefited from other action treatments. Evaluation (n = 43). Significant improvements at post-treatment on all EDI subscales, all BSI scores, QOLI, and readiness for change. Follow-up data collection is underway.
Follow-up groups – Weekly outpatient groups for graduates of action phase treatments.
Meal support – Supported meals are available on an as-needed basis to program graduates.
Quest completers = 84%
In Quest, early discharge was associated with more severe psychiatric symptomatology and higher drive for thinness at admission.
1. 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.
2. Geller, J., Drab-Hudson, D., Whisenhunt, B., & Srikameswaran, S. (2004). Readiness to change dietary restriction predicts outcomes in the eating disorders. Eating Disorders: The Journal of Treatment and Prevention,12, 209-224.
3. 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.
4. Derogatis, L. R. & Spencer, P. M. (1982). The brief symptom inventory (BSI): Administration, scoring, and procedures manual. Towson, MD: Clinical Psychometric Research.
5. Garner, D. (1991). Eating disorder inventory-2: Professional manual. Odessa, FL: Psychological Assessment Resources.
6. Frisch, M.B., Cornell, J., Villanueva, M., Retzlaff, P.J. (1992). Clinical validation of the Quality of Life Inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment, 4, 92-101.
