Acceptance and Commitment Therapy for Eating Disorders

ACT.  Acceptance and Commitment Therapy for Eating Disorders

Act (pronounced as one word–as in “action”) stands for Acceptance and Commitment TherapyACT was developed by Steven Hayes, Ph.D. and is part of the “third-wave” of behavioral therapies (of which Dialectical Behavior Therapy and Mindfulness-Based Cognitive Therapy are also part of).  At its’ core, ACT is about helping individuals take mindful, values-guided action in order to create a rich, meaningful life.

ACT takes the premise that life consists of pain.  Part of the human experience is that we all will experience times when we struggle with painful thoughts and feelings.  Whereas traditional cognitive-behavioral therapy is focused on changing the content of those negative thoughts and feelings so that they no longer hold individuals back from setting goals and taking action that enrich their lives.  This is done by helping people (1) mindfully observe and accept their experiences, (2) distance and disentangle themselves from unhelpful thoughts, and (3) take actions that will enrich their lives.

Although in the course of ACT, many people find symptoms decrease, the goal of ACT is never to outright control symptoms, but instead to encourage individuals to make behavioral choices consistent with what matters to them at their core.

Why is ACT clinically appropriate for an eating disorder patient population?

Eating disorders are often accompanied by high degrees of experiential avoidance, or strong urges to control or avoid negative thoughts and emotions.  One of ACT’s primary goals is to accept whatever negative thoughts and feelings arise in order to make room to behave in values-consistent ways.  To my knowledge, no research has yet been conducted using ACT in randomized clinical trials in the treatment of eating disorders.  However, research has demonstrated ACT to be effective for disorders that have components of experiential avoidance (e.g., substance abuse, chronic pain, depression) and case studies have found ACT to be effective in the treatment of eating disorders.

Explain components of ACT and cite examples of how one would use ACT with a patient with a formal eating disorder.

Many, if not all eating disorder patients, tend to be driven by thoughts about body shape and weight.  For example, one might repeatedly have the thought “I’m fat.  I cannot stand to gain weight.”  Rather than debate the validity of this thought, ACT asks individuals to consider how helpful this thought is in terms of living consistently with one’s values.  That is, the patient may be asked, “When you focus on this thought–when this thought pushes you around, does it lead to the kind of life you ultimately want to live or what you want to stand for in life?”

Then, the patient might be taught ways to step back and defuse, or separate, from this thought.  This can be done as simply as saying, “I’m noticing that I’m having the thought that I’m fat and cannot stand to gain weight.”  Cognitive diffusion can also be strengthened through multiple experiential exercises, such as viewing the words on a computer screen, seeing them as clouds passing through the sky, or leaves drifting down the stream.  The goal of these exercises is to cultivate mindful, acceptance of one’s experience and see thoughts as just words–cognitive events that do not have the power to harm us or have to guide our behavior.

Finally,  the patient would be helped to identify and connect with their deepest values and what they want to stand for in life.  At the end of my life, what do I want people to say about me?  How do I want to act towards others in my life?  If I woke up tomorrow and did not have this eating disorder / depression / anxiety, what would I be doing differently?   For many, thinness is really a means to an end.  ACT helps someone clarify what “end” means to them (e.g., being more connected with others) and helps them develop goals based on these values versus being enslaved by thoughts about thinness.

How has my clinical experience in the treatment of eating disorders influenced my treatment approach and what other theoretical orientation would I recommend?

My experience in treating eating disorders has taught me at least two things.  One, no cookie cutter approach works for everyone.  In my work, some people have shown tremendous progress using cognitive-behavioral methods (e.g., disputing and replacing negative thoughts) or interpersonal therapy.  Other people have responded really well to ACT and more mindfulness-based therapies.  When I review the research, I have found there is no lack of valuable tools out there.   I think that each person needs to ask themselves–“What will likely work best with this particular individual and his/her unique presentation of strengths and struggles?”

Two, I really think that as therapists our conceptualization and view of our patients’ problems are important in their recovery.  If we see someone as resistant and unlikely to change, they probably won’t.  However, if we see them as ‘stuck, not broken,’ we can accept them where they are and work to help them make the changes needed to live a vital, meaningful life.