Motivational change in an inpatient anorexia

nervosa population and implications for treatment

Tracey D. Wade, Anna Frayne, Sally-Anne Edwards, Therese Robertson,

Peter Gilchrist

Objective: The relationship between motivation and recovery in anorexia nervosa has
received increased attention in the research literature although few controlled
investigations of increasing motivation in this population exist. Three questions were
therefore examined in an inpatient anorexia nervosa population: (i) does baseline
motivation predict change in eating pathology; (ii) does change in motivation predict
change in eating pathology; and (iii) can we increase motivation to recover in this group?
Method: Inpatients (n
47) in a specialist weight disorder unit with a mean age of
21.85 years (SD
5.37) were randomly allocated to receive four sessions of motivational
interviewing with a novice therapist in addition to treatment as usual (n
22) or treatment
as usual alone (n
25). Assessment of eating pathology and motivation to recover was
conducted on three occasions: at admission (baseline), and at 2- and 6 week follow up.
Eating pathology was assessed using the Eating Disorder Examination and self-reported
motivation was assessed using the Anorexia Nervosa Stages of Change Questionnaire
and six Likert scales.
Results: Higher baseline motivation across five of the seven measures predicted
significant decreases in eating pathology, and increased Anorexia Nervosa Stages of
Change Questionnaire scores between baseline and 2 week follow up predicted significant
improvement in eating pathology between baseline and 6 week follow up. Significantly
more patients were lost to follow up from the treatment as usual compared to the
motivational interviewing group. More patients in the motivational interviewing condition
moved from low readiness to change at baseline to high readiness to change at 2 and
6 week follow up.
Conclusions: Motivation is an important predictor of change in anorexia nervosa and
preliminary evidence is provided that motivation can be improved in this population. Further
investigations, however, of ways of improving motivation in this population need to be
conducted, along with the impact of motivational changes on treatment outcome.
Key words: anorexia nervosa, motivational interviewing, stages of change.

Australian and New Zealand Journal of Psychiatry 2009; 43:235 243 

Tracey D. Wade, Professor (Correspondence); Anna Frayne, Clinical
Psychologist; Sally-Anne Edwards, Clinical Psychologist; Therese
Robertson, Clinical Psychologist
School of Psychology, Flinders University, PO Box 2100, Adelaide, SA
5001, Australia. Email: tracey.wade@flinders.edu.au
Peter Gilchrist, Consultant Psychiatrist
Weight Disorder Unit, Flinders Medical Centre, Adelaide, South
Australia, Australia
Received 16 September 2008; accepted 28 October 2008.
Anorexia nervosa (AN) has been distinguished
from other Axis 1 disorders in that it is pervasively
associated with ambivalence and variable motivation
for recovery [1]. This phenomenon has been partly
attributed to the ego-syntonic quality of the illness,
referring to the ‘sense of pleasure, accomplishment,
and moral virtue anorexics derive from their pursuit
of thinness’ [2] and it has been proposed that AN may

# 2009 The Royal Australian and New Zealand College of Psychiatrists

236 MOTIVATIONAL CHANGE AND ANOREXIA NERVOSA
serve a functional purpose by providing identity and
a sense of self-worth, despite serious health risks [3].
Treatment is therefore often undertaken reluctantly
in response to pleas and demands by family, friends,
or medical practitioners and other practitioners, and
is characterized by high levels of dropout and poor
outcome [4].
Poorer outcome in AN has been variously asso-
ciated with a wide range of variables, including
younger age of onset, longer duration of symptoms,
a lower body mass index (BMI), longer time spent as
an inpatient, use of purging, and obsessivecompul-
sive personality [4]. Baseline motivation, however,
has been shown to be a powerful and consistent
predictor of outcome. Patients in an AN specialist
residential treatment programme categorized as hav-
ing high readiness to change were more than five
times likely to have a favourable short-term outcome
than patients who were categorized as having low
readiness to change [5], and higher levels of motiva-
tion account for almost 19% of the variance of weight
gain in the first 4 weeks of hospitalization [6].
The transtheoretical model provides a framework
for conceptualizing motivation for change in which
the process of change is divided into five stages [7].
The first stage, pre-contemplation, refers to being
unaware or unwilling to change while the second
stage, contemplation, refers to thinking about
change. These two stages can be seen to represent
low readiness to change [5]. High readiness to change
is associated with the last three stages: preparation
(having the intention of changing soon), action
(actively working to bring about change) and main-
tenance (working towards relapse prevention).
Higher levels of readiness for change have been
shown to correlate with positive behavioural change
across a variety of problems [8], and the model
predicts that treatment failure occurs because the
treatment approach does not match the patients’
stage of change [7]. The relevance of this model for
AN has received growing attention as evidenced by
the development of an assessment tool specific to AN,
namely the AN Stages of Change Questionnaire
(ANSOCQ) [6].
It has been suggested that motivational interview-
ing (MI) may be beneficial for engaging individuals
with AN in treatment [9], a therapeutic approach
derived from the transtheoretical model as a means to
help people work through ambivalence and commit
to change. A meta-analysis of 72 clinical trials
spanning a range of target problems (including
alcohol, smoking, HIV, drugs, gambling, diet and
exercise) found that the average short-term between-
group effect size of MI was 0.77, decreasing to 0.30 at
1 year follow up [8]. Results of the meta-analysis
suggested that the effects of MI appeared to persist or
increase over time when added to an active treatment,
which has been attributed to its effects on treatment
retention and adherence.
To date there is little evidence in an AN population
to suggest that increasing motivation improves out-
come or that we can increase motivation to recover.
Of only five studies that have evaluated MI for the
treatment of eating disorders, two were involved
women with binge eating disorder or bulimia nervosa
[10,11] and three involved AN. Of these three latter
studies, none adopted a randomized controlled de-
sign. The first of these included 12 women with AN in
a group of 19 eating disorder patients and evaluated a
pre-treatment motivational enhancement group inter-
vention [9]. Results of that study suggested that
motivation to change increased following the inter-
vention. At the 6 week follow up, 90% of participants
had entered specialized treatment for the eating
disorder. The second was a case series examining
the impact of a motivational assessment interview on
adolescents with AN [12]. Motivation was assessed to
have improved significantly and 80% of the group
engaged in an outpatient treatment for AN.
The third study, by Dean et al., was a non-
randomized controlled sequential trial comparing
motivational enhancement therapy (MET) to a treat-
ment-as-usual (TAU) comparison group with 42
consecutive admissions to an inpatient eating disor-
der unit, in which 50% of the participants met DSM-
IV criteria for AN [13]. In addition to taking part in
the standard hospital programme, patients in the
MET group commenced therapy within the initial
2 weeks of admission, attending four sessions over
4 weeks. The MET sessions were designed to encou-
rage participants to engage in the standard cognitive
behavioural hospital programme. Dean et al. found
no significant differences between the two treatment
groups on any of the formal measures. At 6 week
follow up, however, 94% of MET completers com-
pared to 45% of TAU completers were engaged in
appropriate levels of treatment. It was concluded
that, in the context of a small sample size and short
follow-up period, results of the study suggested that
MET could potentially be useful in improving the
outcome of brief inpatient hospitalization for patients
with eating disorders.
In order to increase our understanding of the role
of motivation in the process of recovery in AN, there
were three aims of the current study with respect to
an inpatient AN population, assessed over three
 T.D. WADE, A. FRAYNE, S-A. EDWARDS, T. ROBERTSON, P. GILCHRIST 237

waves, at admission to hospital (baseline), and at 2
and 6 week follow up. The first aim was to examine
whether baseline motivation predicted improvement
in eating pathology. The second was to examine
whether improved motivation between the baseline
and 2 week follow up predicted improvement in
eating pathology between the baseline and 6 week
follow up. Finally, within the design of a randomized
controlled trial that conformed to CONSORT guide-
lines [14], we investigated whether four sessions of MI
conducted by novice therapists added to TAU
compared to TAU alone could significantly improve
motivation to recover and eating pathology.
Method
Participants
Eligible participants were inpatients at a specialist weight
disorder unit in Adelaide who: (i) were on either a 2 week (n

34) or 6 week (n
13) inpatient programme, (ii) were ]16 years,
and (iii) met the criteria for AN (excluding loss of menses and BMI
B19 kg m 2). The incorporation of women who met both full-
and subthreshold criteria for AN was considered vital in order to
increase recruitment rates in a population notorious for treatment
resistance and high dropout rates, and justified on the basis of
previous research showing this group to exhibit no differences with
respect to psychopathology to women with AN who met full
criteria [15,16].
Over a 19 month recruitment period 84 inpatients met the
selection criteria; 21 (25%) declined to participate; 47 (56%)
consented; 16 (19%) were not recruited for various reasons (e.g.
participating in another study, self-discharged prior to assessment).
Of the 47 people who participated, there were two male and 45
female subjects aged between 16 years and 37 years (mean

21.85 years, SD
5.37); 11 patients (23%) were 518 years of
age. The mean BMI of this group at Wave 1 was 16.38 kg m 2
(SD
1.5) and increased significantly at Wave 3 to 16.89 kg m 2
(SD
1.6, t(41)
2.39, p
0.02). The study was approved by the
Flinders Clinical Research Ethics Committee and written informed
consent was given by participants.
Procedure
Inpatients were visited within 3 days of their admission and
introduced to the study. Following written informed consent, the
self-report questionnaire was completed and participants were
informed of their randomization to the MI (n
22) or TAU (n

25) condition (one male subject was randomly allocated to each
condition), and the Eating Disorder Examination (EDE) [17] was
conducted by one of four MI therapists (three female and one
male), all of whom were postgraduate clinical psychology students.
Randomization was stratified by treatment programme: 2 or
6 weeks. The aim of the 2 week inpatient programme was to
support patients in contemplating change and to assist them to
determine whether they are ready to engage in the longer 6 week
weight gain inpatient programme. The random allocation sequence
was generated by block randomization, a computer-generated
random number sequence that takes into account the distribution
of previous allocations so that groups will be approximately the
same size. Primary responsibility for generation of the random
allocation sequence was taken by one of the research team not
involved in providing MI.
Participants randomized to the MI condition were invited to
attend four individual 60 min sessions of MI (average attendance
was 3.5 sessions, ranging from two to four sessions) over the initial
2 weeks of their admission. The TAU condition consisted of input
from a multi-disciplinary team. The content of the four sessions of
MI are summarized in Table 1. Therapists were instructed to
conduct sessions in a manner consistent with MI style (collabora-
tive, calm and caring, showing genuine concern, avoidance of
arguments and taking guidance from patients’ reactions as to the
direction of the session), and structured the sessions around
worksheets developed by Treasure and Schmidt [18]. MI sessions
were taped so that supervision could be provided by a clinical
psychologist experienced in the treatment of eating disorders
(TDW). It was difficult to formally assess MI compliance of each
session given that these were structured around the information

Table 1. Content of motivational interviewing sessions

Session Content of session Homework: worksheets

1 Explored how AN affects many domains of patient’s life Explored importance and ability to
(physical, psychological, spiritual and relationships with change using motivational rulers.
family, friends, society and world).
2 Explored patient’s motivation to change using homework sheet. Understanding relationship with AN (good
Pros and cons of AN explored using decisional balance questionnaire. and not so good times).
3 Explored patient’s relationship with AN using homework sheet Collapsing the future (imagining
to discuss the function, value and meaning of AN in the patient’s life. a future with and without AN).
4 Explored patient’s future using homework sheet, created discrepancy N/A
between current state and where patient wanted to be.
Goal setting for the month ahead.

AN, anorexia nervosa.

238 MOTIVATIONAL CHANGE AND ANOREXIA NERVOSA
that the patient had provided in the worksheets, but informal
assessment of a random selection of one session from each therapist
by TDW suggested that adherence to the MI style was considerable
to extensive [19].
Assessments were conducted at baseline (Wave 1), 2 week (Wave
2) and 6 week (Wave 3) follow up. Assessments were conducted
face to face for participants in hospital and via the telephone for
those who had been discharged. In the latter case, questionnaires
were posted to participants and answers were collected over the
telephone. Two trainee psychologists who were blind to participant
condition conducted the follow-up interviews.
Measures
Demographics
At baseline patients were asked to self-report various demo-
graphic variables that have been previously shown to influence
outcome, including the duration of AN symptoms, age of onset of
AN symptoms, and number of prior hospitalizations for disordered
eating behaviour. BMI was obtained from the case notes, and
presence of purging or objective binge episodes was assessed as part
of the eating pathology interview, described below.
Eating pathology. The EDE [17], a semi-structured interview
that is accepted as the gold standard for assessing eating disorders
[20] was used to assess eating pathology. Although the whole
instrument was administered, only the total EDE score is reported
in the current study, because any behaviours would be expected to
decrease due to force of circumstance (i.e. hospitalization). The total
EDE score is made up of four subscales: weight concern, shape
concern, eating concern and dietary restraint, and assesses mainly
attitudes associated with disordered eating. The internal consistency
in the present study was high, with Cronbach’s alpha of 0.92, 0.94,
and 0.96 at baseline and 2 and 6 week follow up, respectively.
Motivation. The ANSOCQ is a 20-item self-report ques-
tionnaire used to assess readiness to recover from AN by assessing
the stage of change that participants were in with regard to each
symptom of AN, where scores ranged from 1 (pre-contemplation)
to 5 (maintenance), with higher scores indicating higher levels of
readiness to change [6]. Mean item scores were calculated to derive
a total readiness to change score. Rieger et al. demonstrated the
ANSOCQ’s internal consistency, testretest reliability and its
convergent, discriminant, concurrent and predictive validity
[6,21]. Internal reliability in the present study was high at 0.92,
0.95, and 0.96, at baseline, 2 and 6 week assessment, respectively. In
addition to examining the total mean item score, we followed the
convention of McHugh [5] and dichotomized the ANSOCQ such
that patients with scores B2.5 were categorized as having low
readiness to change, and those with scores ]2.5 were categorized
as having high readiness to change.
We also used six self-report questions to assess motivation and
self-efficacy to change AN behaviours, in particular, how impor-
tant, confident and ready participants felt about recovering from
their eating disorder and eating normally and gaining weight [22].
Participants responded to each item of a 10-point scale ranging
from 1
not at all to 10
very. Each item was analysed indepen-
dently with higher scores indicating greater levels of importance,
confidence and readiness.
Statistical analyses
Analyses were conducted using version 14.0 of SPSS (SPSS,
Chicago, IL, USA). In order to address our first aim, namely to
investigate whether baseline motivation predicted a change in
eating pathology, linear regressions were used to examine the
Wave 3 total EDE score as the outcome variable, with the Wave 1
EDE score as the covariate and baseline motivation as the
independent variable across the whole sample.
The second aim, which was to investigate whether improved
motivation between the baseline and 2 week follow up predicted
improvement in eating pathology between baseline and 6 week
follow up, was also explored with linear regressions across the
whole sample using the 6 week follow-up EDE score as the
dependent variable and the baseline EDE as the covariate. The
independent variable was the change in motivation between base-
line and 2 week follow up.
The third aim, which investigated whether we could change
motivation and eating pathology using MI compared to TAU, was
examined using linear mixed model analyses [23]. These analyses
have the advantage over ANOVAs because all participants (despite
missing data from one or move waves) are included in the analyses
and accurate parameter estimates can be attained, based on
participants’ obtained data [24]. The model calculates a regression
line for each individual while controlling for explanatory variables
(fixed main effects). In the present study the fixed main effects were
treatment (MI, TAU), time (2 weeks, 6 weeks), and the covariate,
which was the baseline value of each dependent variable. This
approach allows for direct comparisons between the groups at 2 and
6 week follow up despite any baseline differences between the groups
because it equalizes the baseline scores between the two groups.
Post-hoc analyses were used to examine any significant main
effects and interactions, and the formula MT1  MT2/SDpooled was
used to calculate within-group effect sizes (ES), which assessed the
degree of change for each group’s mean scores from baseline to
follow up. MT1 refers to the raw mean score at baseline, MT2 refers
to the raw mean score at 2 week (or 6 week) follow up, and SDpooled
refers to the mean SD for both groups combined at baseline. It has
been proposed that 0.20 is considered to be a small effect, 0.50
moderate, and 0.80 a large effect [24].
Results
Descriptives of group membership
As shown in Table 2, despite random allocation to treatment
condition, some significant differences between the two groups
existed at baseline. Independent samples t-tests found statistically
significant differences in age of patients, in that patients in the MI
group were significantly older than patients in the TAU group.
Duration of AN symptoms at baseline was also significantly
different between participants, in that those with longer duration
 T.D. WADE, A. FRAYNE, S-A. EDWARDS, T. ROBERTSON, P. GILCHRIST 239

Table 2. Baseline subject characteristics

Variable MI (n22) (Mean9SD) TAU (n25) (Mean9SD) Statistics

Demographic variables
BMI ( kg m2) 16.5891.17 16.1491.64 t(45)
1.03, p
0.31
Age (years) 24.2896.37 19.7193.10 t(45)
3.19, p B.001
Duration of AN symptoms (years) 6.9397.22 3.1693.41 t(45)
2.34, p
0.02
Age of onset of AN (years) 16.8894.69 16.4692.84 t(45)
0.38, p
0.71
No. hospitalizations 1.8692.75 1.2092.31 t(45)
0.90, p
0.37
Binged and/or purged (n, %) 16 (72.7) 12 (48) x2 (1)
2.97, p
0.09
Motivation variables
ANSOCQ 2.4090.47 2.5790.69 t(44)
0.95, p
0.35
Low readiness to change (n, %) 16 (72.7) 9 (37.5)
High readiness to change (n, %) 6 (27.3) 15 (62.5) x2 (1)
5.74, p
0.02
Recovery from eating disorder
Importance 8.4192.09 8.2992.33 t(44)
0.18, p
0.86
Confidence 5.6891.94 6.0092.28 t(44)
0.51, p
0.62
Readiness 5.7791.85 6.3592.43 t(44)
0.91, p
0.37
Eat normally and gain weight
Importance 6.0992.86 6.8793.15 t(43)
0.87, p
0.39
Confidence 5.7391.93 6.1091.99 t(44)
0.65, p
0.52
Readiness 5.6492.15 6.4692.40 t(44)
1.22, p
0.23
Eating Pathology
Total EDE score 3.8591.40 3.4391.35 t(44)
1.02, p
0.32

AN, anorexia nervosa; ANSOCQ, AN Stages of Change Questionnaire; BMI, body mass index; EDE, Eating Disorder Examination; MI,
motivational interviewing; TAU, treatment as usual.

were in the MI group. Therefore, age and duration of AN
symptoms were entered as covariates in all analyses that compared
these two groups. With respect to the motivation and eating
pathology variables, no significant differences were found between
the groups, with the exception of the stage of change of the
participants. At baseline, significantly more participants in the
TAU condition were categorized as high readiness to change than
those in the MI condition. At the 6 week follow up there was no
difference in days in hospital between the two groups, with
participants in both the MI and TAU group spending an average
of 21 days in hospital, with respective SDs of 11.86 and 11.83.
Attrition rates
As can be seen in Figure 1, the overall attrition rate at 6 week
follow up was 17.0%, and 78.7% of those recruited completed both
the self-report questionnaire and the clinical interview and 4.3%
completed only the questionnaire or the interview. Of the eight
participants who withdrew, significantly more came from the TAU
(n
7, 87.5%) than the MI group (Fisher’s exact test (one-sided)

0.03). In other words, participants from the TAU group were 1.33
times (95% confidence interval
1.031.72) more likely to with-
draw from the study than the MI participants.
Baseline motivation and change in eating pathology
In order to examine whether any covariates should be included in
the following analyses, the relationship between five baseline
demographic variables and the change in the total EDE score over
the 6 week period was examined. There were no significant
relationships between the demographic variables and changes in
psychopathology, including duration of the AN (b
0.10, p

0.39), age of onset of AN (b
0.02, p
0.88), baseline BMI (b

0.02, p
0.84), purge/binge behaviour (b
0.08, p
0.50), and
number of previous hospitalizations for disordered eating (b

0.04, p
0.75). Therefore, no covariates were included in the
regressions examining motivational variables, with the exception
of the total EDE score at baseline, the results of which are shown in
Table 3. It can be seen that across the whole sample, five of the six
single Likert scale motivational variables predicted change in the
total EDE score, in that higher levels of baseline motivation
predicted a decrease or improvement in the total EDE score
between baseline and 6 week follow up. Confidence in ability to eat
normally and gain weight and the total ANSOCQ score did not
predict a change in the EDE score.
Changes in motivation and changes in eating pathology
The relationship between changes in motivation between baseline
and 2 week follow up and the changes in the total EDE score
between baseline and 6 week follow up is also shown in Table 3.
Across the whole sample, only changes in the total ANSOCQ score
over a 2 week period predicted change in eating pathology over a
6 week period, where increases in motivation predicted decreased
eating pathology.
240 MOTIVATIONAL CHANGE AND ANOREXIA NERVOSA

84 Eligible patients

37 Excluded
21 refused participation
16 participating in another study
Enrolment or discharged self prior to
assessment

47 Patients randomized

22 Assigned to MI 25 Assigned to TAU

15 Received allocated
intervention
7 Terminated prematurely
(5 Discharged self from
hospital early; 2
Allocation dissatisfied with treatment)
68.2% attended all 4 MI
sessions; 22.7% attended 3
MI sessions; 9.1%
attended 2 MI sessions
20 Received allocated
intervention
5 Terminated prematurely
(4 Discharged self from
hospital early; 1 expelled
from hospital programme)

1 Lost to follow up 7 Lost to follow-up

Follow up 1 Unavailable (4 Unavailable; 3 Refused
further participation)

22 included in primary 25 included in primary

Analysis analyses analyses

Figure 1. Flow of participants through treatment. MI, motivational interviewing; TAU, treatment as usual.

Impact of MI versus TAU on motivation
Table 4 lists the estimated marginal means and standard errors
over time for both programmes. No significant timeprogramme
interactions or main effects of group were found. A significant
main effect of time, however, for the Motivation to Change Scale
items ‘Importance of recovering from the eating disorder’ (F
5.04,
p
0.03) and ‘Importance to eat normally and gain weight’ (F

4.79, p
0.04) was indicated. In the first instance, across both
groups, there was a small increase in motivation over the 2 week
follow up but a significant drop in motivation below baseline at
6 week follow up. With respect to importance of eating normally
and gaining weight, the MI group increased in motivation at the
2 week follow up and then significantly decreased at 6 week follow
up, but did remain above baseline. In contrast, the TAU group had
a small increase followed by a significant decrease and ending
below baseline. We also examined whether the total EDE changed
over time differently between the groups and, although no
significant effects were found, it can be seen after a initial decrease
in both groups between baseline and 2 week follow up: the total
EDE score for the MI group continued to decrease between 2 and
6 week follow up, whereas it increased for the TAU group.
When looking at the dichotomous categorization of the AN-
SOCQ, of the 15 patients in the MI condition who were categorized
as having low readiness to change at baseline (and who completed
the ANSOCQ at both time points), nine (60%) had moved to high
readiness to change at 2 week follow up and six stayed at low
readiness to change. In contrast, of the seven patients in the TAU
condition who were categorized as having low readiness to change
at baseline (and who completed the ANSOCQ at both time points),
only one patient (14.3%) moved to high readiness to change at
2 week follow up and six (85.7%) stayed at low readiness to change
(Fisher’s exact test (one-sided)
0.059). The effect size was
moderate to strong (Cohen’s w
0.43), where an effect size of 0.3
is considered moderate and 0.5 strong [25]. This pattern of results
 T.D. WADE, A. FRAYNE, S-A. EDWARDS, T. ROBERTSON, P. GILCHRIST 241

Table 3. Predictors of total EDE score at 6 week follow up

Baseline EDE Motivational Change motivational

total variable variable
Motivational variable b p b p Adjusted R2 b p Adjusted R2
Importance of recovering 0.67 B0.001 0.27 0.02 0.61 0.01 0.97 0.53
from AN
Confidence in ability to 0.56 B0.001 0.34 0.01 0.62 0.03 0.80 0.54
recover from AN
Readiness to 0.64 B0.001 0.33 0.004 0.64 0.15 0.20 0.56
recover from AN
Importance of eating 0.53 B0.001 0.44 B0.001 0.69 0.12 0.30 0.55
normally and gaining weight
Confidence in ability to eat 0.64 B0.001 0.22 0.09 0.57 0.12 0.28 0.55
normally and gain weight
Readiness to eat normally 0.52 B0.001 0.41 0.002 0.65 0.12 0.29 0.55
and gain weight
Total ANSOCQ score 0.67 B0.001 0.14 0.30 0.55 0.28 0.01 0.62

AN, anorexia nervosa; ANSOCQ, AN Stages of Change Questionnaire; EDE, Eating Disorder Examination.

was identical at 6 week follow up, indicating that the move from
low readiness to change to high readiness to change was maintained
at 6 week follow up.
Conclusions
The current study investigated the role of motiva-
tion and its ability to predict change in disordered
eating pathology and the efficacy of MI in enhancing
readiness for change in inpatients with AN. With
respect to our first aim, we found baseline motivation
to be a significant predictor of change in eating
pathology. Four of our six motivational variables
accounted for between 61% and 69% of the variance
of change in the total EDE score when taking into
account the initial EDE score. In contrast, demo-
graphic variables that have been previously but
inconsistently found to predict change in AN [26,27]
were not significantly associated with change, includ-
ing duration or age of onset of the AN, baseline BMI,
purge/binge behaviour and number of previous
hospitalizations for eating problems. The baseline
single Likert Motivation to Change Scales accounted
better for change than the ANSOCQ, indicating that
these simple scales may be of value in predicting the

Table 4. Means and within-group effect sizes

MI condition (n 22) Control condition (n25)

Baseline 2 week follow up 6 weekfollow up 2 week follow up 6 week follow up
Variable Mean (Mean9SD) ES (Mean9SD) ES (Mean9SD) ES (Mean9SD) ES
Recovery from eating disorder
Importance$ 8.30 8.5790.48 0.12 7.6590.47 0.30 8.4990.36 0.09 7.8590.36 0.21
Confidence 5.98 6.4090.50 0.20 6.5790.61 0.28 6.9690.37 0.46 6.2990.46 0.15
Readiness 6.27 7.1690.46 0.41 6.9790.66 0.32 6.7390.34 0.46 6.3790.50 0.05

Eat normally and gain weight

Importance$ 6.93 8.2090.55 0.42 7.7590.59 0.27 7.3890.42 0.15 6.3990.46 0.18
Confidence 6.08 5.7690.73 0.09 6.2590.79 0.09 6.1890.55 0.05 6.1790.60 0.05
Readiness 6.46 6.8290.54 0.16 6.4290.65 0.02 6.3990.40 0.03 5.9190.49 0.24
ANSOCQ 2.62 2.7890.16 0.27 2.8390.21 0.35 2.9490.12 0.53 2.8290.16 0.33
Total EDE 3.27 2.8790.28 0.45 2.6090.34 0.51 2.5290.20 0.50 2.6190.25 0.45

AN, anorexia nervosa; ANSOCQ, AN Stages of Change Questionnaire; EDE, Eating Disorder Examination; ES, within-group effect size
between baseline and 6 week follow up. Controlled for age at baseline and duration of AN symptoms.$Main effect of time.
242 MOTIVATIONAL CHANGE AND ANOREXIA NERVOSA
degree of change that can be expected in inpatient
settings. The differences between the motivational
measures highlight the need to continue to investigate
and develop valid, reliable tools in the area of
motivation for change in eating disorders. Overall,
this finding adds to the growing body of clinical
literature [5,6] suggesting that it is important to focus
on motivation in the treatment of AN, a variable that
literature from other clinical areas shows can be
manipulated, and improve the effectiveness of treat-
ment [8].
To date, in the clinical area of AN it has not been
convincingly shown that changes in motivation are
associated with change in treatment. Investigation of
our second question, namely whether improved
motivation between the baseline and 2 week follow
up predicted improvement in eating pathology be-
tween the baseline and 6 week follow up, showed that
it was only change in the total ANSOCQ score that
predicted change in the total EDE score. In contrast
to the results of the investigation of our first aim, it
appears that the single Likert scales do not have
enough variance to adequately assess change in
motivation. The ANSOCQ, a tool mapped on the
transtheoretical stages of change model, and adapted
specifically for AN, is more sensitive for this purpose,
accounting for 62% of the change in eating pathology
along with the baseline eating pathology score. It
would therefore appear important to increase moti-
vation as measured by the ANSOCQ in order to
maximize opportunities for change in eating pathol-
ogy.
With respect to our third aim we investigated
whether four sessions of MI [18], offered by a novice
therapist, would be sufficient to increase motivation
and/or eating pathology in contrast to a TAU group.
Overall, we did not find that MI significantly
enhanced motivation or decreased eating pathology,
but there are two aspects of our results that do
support the suggestion that the utility of MI for
enhancing treatment outcome in AN should be
further investigated. First, there was a significantly
lower dropout in the MI group as compared to the
TAU group in terms of follow-up assessment. In the
face of high dropout of therapy for both outpatient
and inpatient AN ranging from 31% to 63% [2729],
retention of patients in therapy is considered essential
in order to offer potentially useful treatments.
Second, approaching significance at the p
0.06 level
was our finding that more people in the MI group
crossed over from the stage of low readiness to
change to high readiness to change, as measured by
the ANSOCQ. In the context of relatively small
sample, the effect size, which is independent of
sample size, is informative, and suggests an impact
that is moderate. Coupled with the previous finding
that change on the ANSOCQ predicted change in
eating pathology as measured by the total EDE score,
change on this motivational instrument is an impor-
tant therapeutic goal.
Given that only four sessions of MI were offered by
novice therapists, two improvements to our MI
protocol are immediately apparent. First, given the
difficulties of working with an AN population [1], it
may be that use of therapists experienced in working
with AN and who have training in MI is required in
order to maximize the impact of MI. Second, while
two to four sessions of MI is commonly used across
other types of problems [8], it may be that this
number of sessions is an insufficient dosage with such
an intractable disorder as AN. It would not be
unreasonable to suggest that double this number of
sessions might be considered to be a more adequate
preparation for enhancing response to consequent
treatment. A third improvement to the current
protocol is suggested by the nature of our TAU
condition, which for the majority of patients in the
present study was a 2 week inpatient assessment
programme designed to assist patients to contemplate
their motivation to recover from their eating disorder
and to determine their readiness for the 6 week
programme, which is aimed at behaviour change. It
may be possible that we did not see changes in
disordered eating behaviour in response to increases
in motivation because the treatment programme to
which the MI intervention was linked was not
specifically aimed at equipping patients with tools
for behaviour change. This is in contrast to the study
conducted by Dean et al. [13], who aimed MI
techniques at fostering engagement within the cogni-
tive behavioural therapy approach of the inpatient
unit.
A number of limitations of the current study should
be noted. First, it is not possible to attribute changes
in the MI group to the MI sessions per se, rather than
to the additional attention received from the therapist
and the quality of that relationship. As recognized by
Fairburn [30], however, until preliminary data are
available to support new treatments, it would be
premature to implement costly, time-consuming ran-
domized controlled trials. Second, the use of self-
report motivational measures may not be as reliable
as ascertaining motivation through interview. Third,
the 6 week follow up was short and some participants
remained in hospital, hence, future research would be
improved by the addition of longer follow up.
 T.D. WADE, A. FRAYNE, S-A. EDWARDS, T. ROBERTSON, P. GILCHRIST
In summary, results of this research support the
importance of motivation in predicting change in
eating pathology in AN inpatients. In the current
study we report the results of the first randomized
controlled trial for MI in the treatment of AN, and
on balance we suggest that it is worth further
investigating the addition of MI to treatment ap-
proaches for AN. Future research should endeavour
to increase the power of motivational interventions
by adding MI as a prelude to an active treatment
aimed at behaviour change, using expert therapists
and having more sessions than is typically incorpo-
rated in a MI approach.
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