ACT for Eating Disorders
Eating disorders are notoriously difficult to treat. While traditional treatment approaches such as cognitive behavioral therapy involve challenging and reframing thoughts and feelings associated with food and eating, an eclectic approach to treatment is often needed.
Acceptance and commitment therapy (ACT) emphasizes present moment awareness, experiential acceptance, and committed, values-based action and is one approach that has been shown to work well in conjunction with traditional approaches to the treatment of eating disorders.
The following six tips coincide with the six ACT processes, and have been adapted from a chapter on ACT for eating disorders by Adrienne Juariscio, Ph.D, Stephanie Manasse, MS, and Hallie Espel, BIS in the edited volume, “Mindfulness and Acceptance for Treating Eating Disorders and Weight Concerns.” These tips illustrate just some of the ways that ACT can be applied in the treatment of eating disorders.
Help patients understand the connection between their symptoms and their urge to avoid certain internal experiences.
From an ACT perspective, all behavior has a specific function. In the case of eating disorders, the function of symptoms is to help patients avoid unwanted thoughts, feelings or sensations.
Talking to patients about how well these behaviors have worked or not worked for them can drive home the point that while experiential avoidance may reduce suffering in the short term, it has a tendency to prolong and exacerbate suffering in the long-term.
In addition to compounding existing suffering, avoidance often creates new challenges to deal with, such as limiting patients’ abilities to move toward what matters most to them.
Remind patients that learning to feel difficult feelings is a journey and is likely be a lifelong process, but any amount of willingness to accept these feelings is a step in the right direction that lessens the perceived usefulness of eating disorder symptoms.
Help patients see that thoughts are not facts.
Many of us humans have a tendency to believe that thoughts are facts and act accordingly.
An ACT approach to eating disorder treatment involves guiding clients toward understanding that thoughts are not facts and can be stepped back from, examined and even experienced without judgment. This understanding helps patients connect with the reality that thoughts related to their eating disorder do not need to dictate their behaviors. It also creates space for flexible action in the face of whatever comes up, and ultimately this helps clients move toward their values.
Part of helping clients step back or defuse from their thoughts involves the ability to notice when thoughts are arising, which is a skill that can be learned and experienced through mindfulness practice.
In many ways, clients’ abilities to stop engaging in experiential avoidance by instead accepting uncomfortable experiences as well as to defuse from harmful thought patterns hinges on their ability to first notice when they are, in fact, avoiding or fusing with their thoughts.
Jurascio, Manasse and Espel suggest mindful decision-making as one specific application of mindfulness. Applying mindfulness to choices around food behaviors and eating disorder symptoms can help clients check in and ask whether their choices are aligned with their values. If not, this practice creates space for them to choose differently.
Help patients connect with the fact that their identity does not need to be entwined with their suffering.
The ACT process known as self-as-context can be applied in eating disorder treatment as a way of helping patients make contact with the “observer” aspect of the self—the part of them that can contain a range of thoughts and feelings without believing that such mental events define them.
“Therapists may have clients make a list of labels (best and worst) that they attribute to themselves and then have the clients practice observing their worst self (e.g., “ugly”) so that the experience of thinking the self is ugly does not define one’s identity,” write Jurascio, Manasse and Espel.
The self-as-context process is built upon the skills developed in practices that foster acceptance, defusion and mindfulness—all of which help clients contact an experience of the self that is separate and distinct from eating disorder symptoms.
Help clients stay connected with what recovery means to them and why.
Recovering from an eating disorder is extremely challenging work that often involves deep discomfort, fear and anxiety around eating behaviors that have served a specific function for the client, but must be released. As such, it’s important that clients stay connected with why recovery is important to them and what truly matters.
“Values provide a rational for being willing to tolerate aversive internal experiences associated with recovering from an eating disorder,” write Jurascio, Manasse and Espel.
Set goals and check in regularly.
One of the core tenets of ACT is the process of committed action, which puts all other processes into motion. Once values are determined, the processes of experiential acceptance, defusion, mindfulness and the observing self serve to help patients live out what matters most to them in spite of internal and external challenges.
Clients should be encouraged to ask themselves questions about how well their behaviors have aligned with the values they’ve determined in previous sessions, and to strategize ways to behave differently if it seems they’ve gone off course.
Though eating disorders are arguable one of the toughest mental health challenges to treat, there is promising empirical support for the application of mindfulness and acceptance based strategies like ACT.