Acceptance and Commitment Therapy for Eating Disorders: How can it help?
As published on Psychology Today.
Are you struggling with an eating disorder and looking to start treatment, but not sure what the process will entail? You’re not alone. It’s hard to know what to expect from therapy, given that treatment varies depending on what mental health concern you’re struggling with, or what framework your therapist specializes in. So, let’s review what you can anticipate from the eating disorder field in particular.
Let’s start with the basics. We know that the gold standard, evidence-based treatment for eating disorders is what is called Cognitive Behavioural Therapy (or CBT as it is often shortened to). In simple terms, CBT focuses on changing behaviours and challenging negative thoughts, in order to improve mood. When it comes to eating disorders, the single, most important behaviour change is to establish a pattern of regular eating. Whether it’s in the context of anorexia or binge eating, restriction (aka, not eating enough) is a hallmark “symptom”, so the antidote to this is to get into the habit of eating regular meals and snacks. Sounds simple enough, but the problem is, this is challenging to do. Restriction often occurs in the context of body image concerns and fear of weight gain, so it’s more complex than just saying, “well just eat more.”
While CBT addresses this barrier by tackling thoughts, it is less helpful in targeting the emotions, such as fear and anxiety, that often impede behaviour change. CBT therapists will often ask “what is the evidence for or against this thought?” in the hopes that the individual will be able to produce a more “balanced” thought. However, emotionally charged thoughts are inherently “irrational”, and for many clients that I’ve worked with, this process leads into circle arguments with oneself, whereby it’s easy to vacillate between the devil on one shoulder and angel on the other.
Enter Acceptance and Commitment Therapy (or ACT as I’ll refer to it as from here on out). Over the past 10 years or so, we have built up more and more evidence that this form of treatment thrives where other approaches like CBT may fall short, in learning how to accept and tolerate challenging emotions, rather than rationalize one’s way out of them. ACT can be broken down into three core processes that are actively taught and practiced in therapy: 1) Acceptance and distress tolerance, 2) Mindful awareness, and 3) Values clarification and commitment. The remainder of this article will outline each of the three, with practical examples of how they may be applied in eating disorder treatment.
Acceptance and Distress Tolerance
We live in a world where happiness has been promoted as the ideal, and at the expense of all else. However, people have known for centuries that suffering is inherent to the human condition. When you think about it, how would we even know what it feels like to be happy, to experience joy, without the counterpoint of having experienced disappointment, loss, and sadness?
ACT proposes that the problem with emotions is not that we have them, it’s what we do when we experience them. For many of us, we are taught to make “bad” emotions go away, to force ourselves to “get over it” and move on to happier pastures. However, most people have experienced the backlash to this. Has anyone ever told you to “calm down” when you are absolutely irate? If so, how did you feel? I’ll guess with a high level of certainty that you didn’t feel better, likely, the exact opposite; more angry, for having been told that you shouldn’t be feeling what you were.
It doesn’t have to take someone else saying this to us for the same process to play out. We do the same thing to ourselves. “Don’t feel that.” “It’s fine, get over it.” “What are you worrying about?” But the emotion doesn’t go away, it just gets worse.
Acceptance and distress tolerance is the antithesis to trying to change emotions. Instead, it focuses on sitting with how you feel, in whatever state this is, no matter how unpleasant. In the context of eating disorder treatment, this may mean learning to tolerate urges to restrict, or to binge, without acting on them. When we do this, we uncouple our actions from our internal experiences, learning that just because we have a certain thought or feeling, doesn’t mean we have to act on it. In fact, it will usually go away on its own if we give it time, we just have to allow space for this to happen.
Mindful Awareness
The second process that is central to ACT is that of mindful awareness. Mindful awareness is the ability to pay attention to your internal experience, or the collection of thoughts, feelings, and physical sensations that you may have at any given point in time. Mindful awareness goes hand in hand with acceptance. In order to accept your feelings for what they are, you first have to be aware that you are having them.
ACT promotes a core tenet of “contact with the present moment”. If you look at our everyday lives, you quickly realize how rarely we are actually present. More often, we are off in the future, making plans for what we would like to happen, or worrying about things that likely won’t happen. Alternately, we may find ourselves in the past, ruminating about what did or didn’t happen, although nothing can be done to change that in the here and now. When you are present and immersed in the experiences you are having, there is not space to be anxious. ACT cultivates this presence through breathing and other meditative practices.
Regardless of your thoughts on meditation, it’s a tool to train your attention; a pragmatic way to practice bringing yourself back to the here and now. I love teaching clients to practice body scan meditations, simply paying attention to the physical sensations you experience throughout your body at any given point and time, particularly in the context of eating disorders. Because food, eating, and body image become so interconnected, people often learn to disconnect from their bodies as a way to avoid distress. Bringing all of these sensations back online becomes a way to reconnect with your body and your emotions, and learn to build healthier relationships with them.
Values Clarification and Commitment
The final, and probably my favourite, component of ACT is the notion of values clarification and commitment. Simply put, our values are the things in life that are important to us. Knowing what your values are and why they are meaningful to you can serve as the compass for living a life that goes in accordance with being the person you want to be, and feeling satisfied as a result.
When it comes to eating disorders, values can get a little murky. Core values like compassion, flexibility, and autonomy, may get confounded with desires to be thin, to fit in, or to be liked. While these latter values aren’t inherently bad, the way in which we go about pursuing them does matter. For example, wanting to fit in and connect socially is reasonable, even desirable, but if you feel you have to attain a certain shape or size to accomplish this, you’ll likely wind up on a proverbial treadmill that’s difficult to get off. In therapy, we often look at alternative pathways for achieving values that don’t rely on disordered eating behaviours to be fulfilled.
The other thing I often witness with eating disorders is that values become less and less diverse over time. Someone may have previously had a number of different hobbies, interests, and passions that made up who they were and what they cared about, but over time, their eating disorder came to eat up more and more of this space. Values commitment means building a life outside of disordered eating, often rediscovering old interests, or creating new ones, and incorporating these valued activities into one’s day to day. While CBT also focuses on “doing”, it’s less interested in the “why” behind the doing. Conversely, in ACT, we acknowledge that it’s important to break down someone’s motivation and meaning behind various values (i.e., the values clarification piece) before enacting these values in everyday life (i.e., values commitment).
Conclusion
Eating disorder therapy focuses on changing restrictive eating patterns and replacing them with a regular pattern of meals and snacks. Acceptance and Commitment Therapy (ACT) enhances this process by focusing on learning to tolerate uncomfortable experiences while still living a life that is in line with one’s values. If you’re looking to pursue therapy of this nature, you can expect to learn strategies to sit with distressing emotions, rather than acting on them, while also exploring what you care about and taking steps to enact this on a regular basis.