Acceptance and Commitment Therapy (ACT) in the Treatment of Eating Disorders

A Radically Different Approach

 

Fighting an Eating Disorder (ED) is usually an extremely challenging task in large part due to the relentless and intrusive nature of the thoughts, feelings and sensations involving one’s body and eating habits. Patients often engage in harmful behaviors such as restricting and purging in the hopes that these behaviors will help “eliminate” or reduce their ED thoughts and feelings. A patient might think, “if I restrict my food intake today, my body dissatisfaction thoughts will get quieter” or “if I purge the breakfast I just ate, my anxiety about all those calories will be relieved.” While ED behaviors might provide some short-term internal relief, they are not effective long-term coping strategies. Paradoxically, while eating disorder behaviors might provide some initial relief, over time negative emotions often increase. It makes sense then why patients might feel even more compelled to engage in disordered behaviors in pursuit of continuing to experiencing some short-term relief.

Acceptance and Commitment Therapy (ACT) provides patients with an alternative to attempting to “get rid of their ED thoughts and feelings.” The alternative involves a shift in attention from what is often largely out of their control to what is in their control. Patients are usually not in control of the rate and intensity at which ED thoughts pop into their minds. However, patients are in control of their actions as well as how they choose to respond to their thoughts. ACT, an offshoot of Cognitive Behavioral Therapy, uses a series of metaphors to teach patients acceptance-based strategies that will help disempower the influence of their ED thoughts over their behaviors. ACT also emphasizes a focus on identifying one’s values and committing to act in ways that are in line with one’s chosen values.

Passengers on the Bus Metaphor

In this popular ACT metaphor, patients are taught that navigating through life with an eating disorder is like being the driver of a bus full of noisy passengers that you can’t throw off the bus. The passengers on the bus represent different thoughts. One passenger might be the “you’re ugly” thought, another passenger might be the “you shouldn’t eat that” thought, and another passenger might be the “it’s all your fault thought.” The metaphor is used to demonstrate that the driver can still arrive at his destination in spite of the noisy and cruel passengers, provided that he stops engaging with the passengers and continues driving towards his destination. Likewise, patients do not need to get rid of their thoughts to be able to attain a life of recovery. Here is a brief video of this metaphor.

 

History & Research

Acceptance and Commitment Therapy (ACT) was developed in the early 1980s by Dr. Steven Hayes, a psychology professor at the University of Nevada. His research has focused on the connection between language and the experience of human suffering. The ACT model was developed throughout the 1980s and 1990s and the first ACT book was published in 1999.

Russ Harris, an Australian physician and therapist, has emerged as an expert ACT trainer and author. His books and training make the process of learning ACT fun and simple, and his popular book “The Happiness Trap” has sold more than half a million copies.

To date, empirical support for ACT as a treatment mode for patients struggling with eating disorders has been promising. Research studies have revealed some significant findings such as:

  • overall improved functioning and decreased disordered eating for patients treated with ACT
  • a reduction in eating disorder symptoms and increases in weight for patients with Anorexia Nervosa treated with ACT who had been previously treated with other treatments and never improved
  • greater satisfaction with one’s appearance for patients who practiced acceptance strategies
  • larger reductions in eating disorder thoughts and behaviors for patients treated with ACT versus cognitive therapy.

The Six Processes of ACT and their Application to Eating Disorders

ACT theory proposes that maladaptive coping mechanisms (such as restriction, purging, over-exercising, calorie counting and obsessive body checking) arise in response to psychological rigidity, a key trait of patients struggling with eating disorders. ACT teaches patients to move from psychological RIGIDITY to psychological FLEXIBILITY through 6 different processes outlined below:

ACT in the Treatment of Eating Disorders

1.  Learning to “defuse” from unhelpful thoughts that one has become “fused” with

In a state of fusion, ED thoughts seem like the absolute truth or commands that have to be followed. For example, when the thought “I am so gross” pops into one’s head, instead of viewing the thought simply as a string of words randomly produced by one’s mind, the thought is immediately believed as if it were a fact.

ACT provides alternative ways to interact with difficult thoughts so that the thoughts will have less impact on one’s behavior. Defusion involves stepping back and observing one’s thoughts without getting caught up in them. Thoughts are simply seen as constantly changing “streams of words, sounds, and images”. Defusion techniques involve playing around with these words, sounds and images so that the content of the thoughts start to seem less relevant in influencing one’s behavior. For example, defusing from the thought “I am so gross” might include saying the thought aloud in a funny accent, singing the thought to a popular tune, or repeating the thought rapidly. There are hundreds of different defusion techniques in ACT literature that can be utilized to disempower the significance of the thoughts. The aim is not to get rid of the thought, but rather to learn to respond more flexibly to the thought. While not a goal of defusion, laughter frequently occurs during practice and patients often realize “how ridiculous” their thoughts sound when they bring their thoughts to life and start to play around with them. This is obviously a radically different approach to strategies that involve engaging in efforts to rationalize or change thoughts.

2.  Moving from experiential avoidance to acceptance

ACT proposes that eating disorder behaviors are maintained by experiential avoidance which occurs when one is not willing to remain in contact with difficult emotions and thoughts and as a result, ED behaviors are used in an attempt to escape difficult thoughts and numb unwanted emotions. Examples include: restricting food intake or over-exercising in the hopes that one will experience fewer “I’m fat” thoughts or dressing in a way that hides most of one’s body in an effort to numb the feeling of shame.

ACT uses a series of metaphors to demonstrate how experiential avoidance is not a long-term solution. Once the patient understands that avoidance is unworkable, acceptance is provided as an alternative and the patient learns that fostering acceptance of their unpleasant internal reality will provide them with more energy and space to engage in other things that are important to them. The ACT therapist will frequently create in-session opportunities that expose patients to difficult ED thoughts and emotions so that the patient can practice acceptance and tolerance. Once the patient becomes more comfortable with and less reactive to their internal experience, there is less of a reason to engage in ED behaviors as a way of coping.

3.  Practicing mindfulness to return one to the present moment

Engaging with ED thoughts takes one out of the present moment because the mind is either engaged in mental planning involving future efforts to alter one’s body or the mind is caught up in the past ruminating about past failures or tracking mistakes to help one better compensate in the future. For example, “My breakfast had too many calories so I’ll have to skip lunch and dinner so that I don’t gain weight.”

ACT is a mindfulness-based therapy. Patients learn to pay attention, with intention, to the present moment, without judgment. When one notices obsessive future weight related fears, mindfulness tools can be used to return one’s attention to the present moment.

4.  Detaching from unhelpful self-narratives

Patients with eating disorders often become attached to unhelpful narratives or stories about who they are. For example, patients might strongly identify with narratives such as “I am unworthy,” “I’ll always be alone” and “I’ll never be good enough.” These self-stories usually develop over time in response to how other people treat them and how they interpret those experiences. Eating Disorders are strengthened when patients become overly attached to the unhelpful stories their minds have created.

ACT uses the concept of an “observing-self” to teach patients that they are not actually their thoughts. While their minds are creators and containers of these self-stories, they do not have to be defined by them. For example, patients can learn to view their internal experiences from an observer’s perspective “I’m noticing that the story entitled I’ll always be alone just popped into my mind, and I can recognize that my mind made up this story because when I was younger, I was bullied and rejected by many of my peers, but I don’t have to buy into this story anymore because it doesn’t serve me.” Taking an observer’s perspective to one’s own mind helps to create distance between who the mind says the patient is and who they actually are at their core. ACT helps patients create new narratives for their lives that will provide stronger foundations for ED recovery.

5.  Clarification of values

Patients often remain stuck in the pursuit of a smaller body due to a poor sense of what else is important to them. Many patients feel that their eating disorders are the core of their identity because their ED provides a special sense of uniqueness.

Values work in ACT targets one’s over-reliance on what society or others have deemed important, such as obtaining a “perfect” body. Clarification of values helps patients identify what kinds of people they want to be, what’s truly important to them and what they want to stand for. Once some values have been identified, patients are taught how their ED behaviors act as a barrier to living a valued-based life.

6.  Committed action in service of values

If a patient’s values are unclear and their time and energy are being consumed by engaging in ED behaviors, it’s likely that patients will stop working towards creating a meaningful life. For example, patients might drop out of school, isolate from their friends and stop volunteering which will move them further away from a life worth living.

This final process of ACT focuses on empowering patients to take committed actions (specific steps) in service of their values. For example patients might commit to contacting their college advisor to begin the process of re-enrolling in classes to work on the value of education which they would have identified in the “values” process of their ACT therapy work.

For more information about ACT, the ACBS website has a wealth of resources for learning ACT.

 

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About the Author:

Chelsea Hudson, LCPC owns Cityscape Counseling in Chicago where she specializes in the treatment of adolescents and adults struggling with a range of Eating Disorders. Before pursuing private practice, she gained extensive training and experience treating Eating Disorders including a clinical internship in the Eating Disorder Program at the University of Chicago focused on Family-Based Treatment/Maudsley Method and a clinical manager role at Eating Recovery Center of Chicago in the intensive outpatient program focused on DBT, ACT and ERP as treatment methods for acute cases of Anorexia and Bulimia. Most recently, Chelsea presented on the use of ACT and Radically Open DBT in Eating Disorder Treatment at Renfrew’s National Center Foundation Conference.

References:

Atkinson, Melissa J.; Wade, Tracey D. (2012). Impact of metacognitive acceptance on body dissatisfaction and negative affect: Engagement and efficacy. Journal of Consulting and Clinical Psychology, 80(3), 416-425.

Berman, M. I., Boutelle, K. N., & Crow, S. J. (2009). A case series investigating acceptance and commitment therapy as a treatment for previously treated, unremitted patients with anorexia nervosa. European Eating Disorders Review, 17, 426–434.

Hayes, S.; Strosahl, K.: Wilson, K. (2012). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. New York, NY: The Guilford Press.

Hayes, S. C., & Pankey, J. (2002). Experiential avoidance, cognitive fusion, and an ACT approach to anorexia nervosa. Cognitive and Behavioral Practice, 9, 243–247.

Heffner M., Sperry J., Eifert G. H., Detweiler M., (2002). Acceptance and commitment therapy in the treatment of an adolescent female with anorexia nervosa: A case example Cognitive and Behavioral Practice, 9, 232–236.

Juarascio, A. S., Forman, E. M., & Herbert, J. D. (2010). Acceptance and commitment therapy versus cognitive therapy for the treatment of comorbid eating pathology. Behavior Modification, 34, 175–190.

Manlick, C.F., Cochran, S.V. & Koon, J. J (2013). Acceptance and Commitment Therapy for Eating Disorders: Rationale and Literature Review. Contemp Psychother, 43 (2), 115 – 122.

Written – 2017