Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

After Weight Restoration: The Role of Motivation

Motivation is the process that initiates, guides, and maintains goal-oriented behaviors. It involves the biological, emotional, social, and cognitive forces that activate behavior. Basically, motivation is what drives us to act.

In eating disorder circles, motivation generally refers to an inner drive to achieve or maintain recovery. Given that anosognosia is a primary symptom of Anorexia Nervosa (AN), most patients have little or no insight or motivation while they are ill. When a person does not perceive herself as ill, she will not be motivated to recover. When a person perceives himself as superior while undernourished, emaciated, and hyperactive, he will be highly motivated to maintain his AN.

Fortunately, motivation is not necessary to begin recovering from AN. In Family-Based Treatment (FBT), motivation is neither expected nor required of patients during Phase I (re-feeding and weight restoration). So long as the parents are highly motivated to return their child to good health (as most parents certainly are), patient motivation is unnecessary.

There are two types of motivation:

Extrinsic motivation is a drive to perform an activity to attain a particular outcome. Extrinsic motivations come from outside the individual. For example, a student is motivated to study in order to earn good grades and gain admission to an elite college.

Intrinsic motivation is an inner drive to perform an activity for personal reasons, based on interest or enjoyment of the task itself. Intrinsic motivation exists even in the absence of external reward. For example, a young artist who is passionate about painting spends hours in the studio completely immersed in her art.

Parenting often involves the use of extrinsic motivation early on, as a pathway to developing intrinsic motivation. A toddler is motivated to use the toilet by getting a star on her chart; a preschooler is motivated to follow her parents’ rules to avoid getting a time-out; a teenager is motivated to be home by curfew to avoid getting grounded.

The ultimate goal of parenting, of course, is for the children to grow into independent adults who are no longer dependent on extrinsic motivation to exist in society. Eventually, the child feels intrinsically motivated to use the toilet because sitting in soiled underpants is uncomfortable; she is kind to her friends and siblings because it is the morally correct thing to do and she wants to maintain good relationships with them; she comes home at a decent hour so that she can get a good night’s sleep and function well the following day.

Similarly, a long-term goal of treatment for Anorexia Nervosa is for the patient to be intrinsically motivated to stay healthy and remain in recovery. But while we wait for intrinsic motivation to develop, it is perfectly fine and, in many instances, absolutely necessary, to impose external motivations in order to nudge the person along towards recovery.

Patients with Anorexia Nervosa often have little or no intrinsic motivation to recover during their acute phase of illness. In fact, most patients are highly motivated to continue engaging in eating disorder behaviors because there are powerful biological, psychological, and social forces compelling them to do so. For this reason, it is often essential to use extrinsic motivations of some sort to get patients to engage in recovery-oriented behavior such as eating meals, gaining weight, refraining from purging, and attending appointments with their treatment team.

Patients with AN are often compliant, rule-abiding people-pleasers. We can harness these traits in a positive way to promote recovery. It is common for patients to report that they are eating and gaining weight to make their parents happy or to please their doctors. It is even more common for patients to comply with re-feeding and maintain their ideal weight in order to avoid hospitalization or continue playing the sport they love.

Parents often worry that, if left to her own devices, their child would most certainly eat too little, exercise too much, start purging again, and fall down the rabbit hole once more. This worry is completely valid, and this is precisely why patients need a very high level of support and monitoring for a long time after diagnosis. Incidentally, the need for a high level of support and monitoring continues for much, much, much longer than what is provided by most treatment programs or paid for by most insurance companies. One of the reasons why patients need such high levels of support for so long is that intrinsic motivation is neither realistic nor possible for most patients until they are further along in recovery.

While acutely ill patients often lack the motivation to recover, many patients who are weight-restored and further along in their psychological recovery feel very motivated to stay well. I believe that there are several reasons for this shift in motivation in the later stages of recovery:

1.) The ability to think more clearly, thanks to a well-nourished brain and body.

2.) Maturity. Patients get older and more mature as they progress through recovery, and thanks to a more developed prefrontal cortex, they can think ahead, make plans, and follow through with their intentions.

3.) Perspective. Patients in the later stages of recovery have often been through hell and back. They have reclaimed their lives, and while they may not remember much of the acute phase of their illness, they know it was awful and they have no intention of going back.

4.) Parental intervention. Parents who have helped their children recover from AN tend to be extremely motivated to help them stay well. Perhaps more importantly, they feel empowered to use the tools and strategies they’ve learned through treatment to maintain an environment conducive to ongoing recovery and to set limits, without hesitation, on any behavior that jeopardizes recovery.

Motivation seems to be the natural consequence of restored health and improved insight. Once an adolescent or young adult is no longer encumbered by AN, he begins to realize how sick he once was, and how much AN ruined his life. As he returns to school, sports, hobbies, and an active social life, he begins to build a life worth living. This new life motivates him to stay in recovery and deters him from engaging in behaviors that could lead to relapse.

I have found that older adolescents and young adults are often motivated to stay in recovery in order to achieve their goals. For example, they want to go away to college or graduate school, they want to study abroad, they want to get married and have children, they want to travel the world, they want to have a rich and meaningful life that is not dominated by intrusive thoughts about carbs or calories or the circumference of their thighs.

How can you enhance motivation in someone who is recovering from AN? Well, intrinsic motivation, by definition, must grow and flourish from within. It cannot be imposed upon someone from the outside. However, there are a few things that family members and clinicians can do which may facilitate development of intrinsic motivation:

1.) Help the person build a full, rich, meaningful life.

2.) Remind the person periodically (not forcefully or frequently) that his new life would not be possible without continued recovery.

3.) Highlight and enhance the personal characteristics that have helped the person achieve and maintain recovery (e.g., “You are such a strong, courageous, dedicated person to have overcome this illness”).

4.) Help the person identify his core values and support him in living a life that is congruent with these values. What is most important in life? How does he want to be remembered by loved ones after he dies? Unless the person is acutely ill with AN, he is unlikely to say that being thin, exercising excessively, or avoiding sugar and flour his core values.

Staying focused on core values and pursuing a meaningful life are powerful motivators and potent antidotes to the anorexic thoughts that come to visit from time to time.

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3 Responses to After Weight Restoration: The Role of Motivation

  1. David says:

    Dear Sarah,

    Thanks for sharing your insight with us. My 16 years old daughter has been weight restored for 3 years. She has been maintaining weight pretty well. Currently she is doing very well in school and other activities. She has very good academic performance and is back to cross-country and track & field for about 3 years. She doesn’t have any exercise compulsion.

    We are trying to give the control back to her. If we feed her and she can eat whatever we ask her to eat. Her weight is pretty good. However, when she eats independently, she still can’t eat enough food. She has hunger hue but that is not accurate.

    The frustrating thing we are facing is: we try to let her eat by herself, she couldn’t eat enough and lose about 1- 2 pounds in a week. Then we take control back and re-feed her, her weight is restored in one week. Once she lost her weight, her physical activity will be stopped. Next week we try again, she still loses weight. This pattern repeats over and over. She feels frustrated and we are still try to help her. Do you have any better suggestion to address this issue?

    Thanks!

    David

    • Dr. Ravin says:

      Hi David,

      This is a challenging and frustrating problem. I have been through this situation a number of times with a number of my patients. The “solution” is not so clear-cut, as each individual is different.

      It is clear that YOU know how to feed your daughter very well, so your job is to impart your knowledge onto her. It sounds like she no longer has trouble eating when food is served to her. The problem most likely lies with her inability to make decisions about food or use her own judgment or intuition about what and how much she needs to eat. The solution, then, would be to not have her in a position of having to make decisions about food, but rather to follow a plan that works.

      It sounds as though your daughter, like many people with histories of AN, cannot rely upon her intuition to fuel herself properly. This is the case for many competitive athletes, not just those who have recovered from eating disorders. It may be helpful for your daughter to have a specific eating plan to follow when she is responsible feeding herself. For example, perhaps you could sit down with her and come up with several different options for high-calorie breakfasts, lunches, snacks, and dinners using foods that she enjoys, paying close attention to the portion sizes to make sure she is feeding herself enough. Sometimes it is necessary to be very specific with the amounts of food that she needs, because she is probably trying really hard to eat enough and is probably eating well, just not well enough to fuel her activity. Supplements can be helpful for athletes with high-calorie needs. For example, your daughter could benefit from protein shakes and protein bars.

      Many people consider “intuitive eating,” or eating based on hunger and fullness without any rules or plans, to be the pinnacle of recovery. However, I believe that intuitive eating is not realistic for many people who have histories of AN. Intuitive eating, like many strategies, is an effective tool for some people but not for others.

      My next thought is that competitive running may not necessarily be the best activity for your daughter. Runners have extremely high energy needs, and it is well known that endurance sports can be triggering for those with restrictive eating disorders. It sounds as though running competitively may be hindering her full recovery, in the sense that she is only able to eat enough to fuel her sport when you are feeding her. It sounds like your family may need to make a choice between your daughter’s full recovery from AN (which involves the ability to feed oneself independently at an age-appropriate level) and participation in competitive running (which requires a very high calorie diet that your daughter is not able to eat on her own).

      If your daughter enjoys sports, perhaps she could play a different sport without such a high energy expenditure, such as volleyball or softball.

  2. Paige says:

    Very insightful post! I can see how motivation is the key to recovery. Thank you for sharing your wisdom!

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