A New Approach for Treating Eating Disorders: Acceptance and Commitment Therapy
By Kathy Kater, LICSW
Reprinted from Eating Disorders Recovery Today
FALL 2009 Volume 7, Number 4
?2009 G?rze Books
While the medical consequences of an eating disorder can be life-threatening, the unrelenting internal dialogue and the compulsion to follow rules and rituals causes most of the suffering. The endless stream of fear-based judgments, rigid demands, and threats can take over a mind and sometimes drive a life into the ground. It is in the face of these "eating disorder thoughts" and the difficult emotions and impulses they provoke that patients must triumph if they are to begin the long road to recovery. Even those who interrupt eating disorder behaviors for weeks, months, or even years remain vulnerable to a re-arising of powerful mental formations that may trigger a relapse.
While it is always tempting to appeal to reason and logic to challenge self destructive thinking—the goal of Cognitive Behavioral Therapy (CBT)—as a seasoned therapist I have not found entrenched eating disorder thoughts to be significantly diminished by rational arguments or objective evidence. Recently, I discovered that the compelling methods of Acceptance and Commitment Therapy (ACT) describe and enhance an approach that I have found works better in helping eating disorder patients move toward recovery.
Acceptance and Commitment Therapy
ACT does not attempt to change the content of irrational or negative thoughts and difficult emotions, even if this is false and destructive. Instead the goal is to help people face these thoughts, see them from a different perspective, andin turn respond in a way that is more helpful.
Research has demonstrated that ACT is highly effective with disorders that are driven by experiential avoidance: a compelling urge to avoid or control difficult internal states such as unpleasant or painful thoughts, emotions, or sensations. While studies using ACT for treating eating disorders have not yet been done, these are certainly driven by a powerful compulsion to get rid of or control disturbing mind and body states. For example, eating disorders sufferers routinely deal with thoughts such as "I"m too fat" (and therefore out of control or unacceptable), or body states like a full stomach by using eating disorder behaviors to temporarily reduce distress or feel in control.
What most eating disorder patients do not recognize is that the very act of trying to avoid internal distress keeps them trapped in a self-perpetuating cycle. Like a Chinese finger trap, the harder we try to escape, the more we are locked in. Repeatedly running away from difficult emotions, whether by not eating, purging, drinking alcohol, or any other "fix," only creates more problems by creating a dependency on avoidance behaviors and teaching nothing about coping with the inevitable difficulties of life.
Acceptance
Helping patients become willing to face their difficult thoughts is the "acceptance" part of ACT. We might say, "Ok, you think you are fat and disgusting." Even though we do not agree with this thought and consider it harmful, we do not argue with or challenge it. Instead ACT uses mindfulness and cognitive defusion methods to help people mentally "step back" and see this thought for what it is: just a thought, i.e. the firing of certain synapses in the brain that may or may not be helpful. Eating disorder thoughts are mental constructions that have formed as a result of separate thoughts and events that have become associated and that are now triggered involuntarily and as if they were one. For example, therapists often hear how associations between feeling bad, not eating, and in some way feeling better or "in control" can be traced to an event such as this one:
Facing ED Thoughts
Just as getting out of quicksand requires a counter-intuitive action, facing eating disorder thoughts without obeying them can seem impossible. Yet it is the only alternative to being enslaved.Once they exist, eating disorder thoughts and impulses cannot be willfully stopped from arising. What is possible is to learn to look at thoughts instead of viewing the world from them.
Mindfulness is a two millennium-old method for creating this distance and objectivity. Mindfulness makes it possible to become aware that in any present moment there is a "me" that is thinking and a "me" that can "watch myself think." When patients first experience this, I often ask them, "Who is watching?" When they become curious about this observing self—a self that transcends their thinking mind—they can see that it is possible to view both their self and their thoughts within a bigger context than they previously knew, creating a space in which new possibilities can arise.
Research has documented that the perspective from which thoughts are viewed can significantly alter their impact. For example, a patient told me, "I can"t stand to feel full—it makes me feel like I will blow up!" When fused with this thought, it seemed literally true to her. From her perspective, eating until full was akin to annihilation! Using mindfulness she was able to learn to observe this thought instead of being caught in it, and it became possible for her to say "I"m having the thought that if I feel full I will explode."
In the space that opened she had room to feel sad that the years of eating only morsels in order to obey this thought had cost her many of her dreams. In her case, being a slave to eating disorder rules had forced her to withdraw from training as a potential Olympic skater. From this new vantage point she could begin to consider whether she might be willing to have this thought, and even tolerate the anxiety it evoked, if it meant she could begin to follow new dreams, such as becoming a skating teacher.
Connecting with an Ultimate Purpose
In line with this, another goal of ACT is helping patients to connect with their deepest values and ultimate purpose in life. What else could generate a willingness to face what torments us and to let go of behaviors that provide an illusion of control? By connecting with values, patients become aware of what they would want to be able to say about their life if their eating disorder thoughts and impulses were not controlling their actions: "In a world where you could choose to have your life be about something, what would you choose?" When patients feel immobilized on the difficult road to recovery, values clarification shines a compelling light on why they must go on.
ACT"s overall therapeutic goal is to help patients ride out the inevitable waves of emotionally-provocative thoughts and impulses while committing to actions that align with what really matters most in their lives. ACT is challenging because it conflicts with some of the basic tenets of Western thought, such as that "pain is bad," "happiness depends on feeling good ("feel-goodism")," and "if you just work hard enough you can get whatever you want." Therapists are hooked by these beliefs in ways that are not all that different from our patients—I know I have been. It has taken me time and practice to integrate ACT into my work. To apply it I must continually ask myself, "What do I do when faced with pain?"The results have been professionally and personally rewarding.
(Note: The Anorexia Workbook by Michelle Heffner and Georg Eifert is a good client resource utilizing ACT principles.)
About the Author
Kathy Kater, LICSW is a psychotherapist in St. Paul, MN who has specialized in treatment and prevention of the full spectrum of body image, eating, fitness and weight concerns for over 30 years. She is the author of the Healthy Body Image curriculum (2005, NEDA), and is passionate about promoting the Model for Healthy Body Image and Weight upon which that curriculum is based (more information at BodyImageHealth.org)
By Kathy Kater, LICSW
Reprinted from Eating Disorders Recovery Today
FALL 2009 Volume 7, Number 4
?2009 G?rze Books
While the medical consequences of an eating disorder can be life-threatening, the unrelenting internal dialogue and the compulsion to follow rules and rituals causes most of the suffering. The endless stream of fear-based judgments, rigid demands, and threats can take over a mind and sometimes drive a life into the ground. It is in the face of these "eating disorder thoughts" and the difficult emotions and impulses they provoke that patients must triumph if they are to begin the long road to recovery. Even those who interrupt eating disorder behaviors for weeks, months, or even years remain vulnerable to a re-arising of powerful mental formations that may trigger a relapse.
While it is always tempting to appeal to reason and logic to challenge self destructive thinking—the goal of Cognitive Behavioral Therapy (CBT)—as a seasoned therapist I have not found entrenched eating disorder thoughts to be significantly diminished by rational arguments or objective evidence. Recently, I discovered that the compelling methods of Acceptance and Commitment Therapy (ACT) describe and enhance an approach that I have found works better in helping eating disorder patients move toward recovery.
Acceptance and Commitment Therapy
ACT does not attempt to change the content of irrational or negative thoughts and difficult emotions, even if this is false and destructive. Instead the goal is to help people face these thoughts, see them from a different perspective, andin turn respond in a way that is more helpful.
Research has demonstrated that ACT is highly effective with disorders that are driven by experiential avoidance: a compelling urge to avoid or control difficult internal states such as unpleasant or painful thoughts, emotions, or sensations. While studies using ACT for treating eating disorders have not yet been done, these are certainly driven by a powerful compulsion to get rid of or control disturbing mind and body states. For example, eating disorders sufferers routinely deal with thoughts such as "I"m too fat" (and therefore out of control or unacceptable), or body states like a full stomach by using eating disorder behaviors to temporarily reduce distress or feel in control.
What most eating disorder patients do not recognize is that the very act of trying to avoid internal distress keeps them trapped in a self-perpetuating cycle. Like a Chinese finger trap, the harder we try to escape, the more we are locked in. Repeatedly running away from difficult emotions, whether by not eating, purging, drinking alcohol, or any other "fix," only creates more problems by creating a dependency on avoidance behaviors and teaching nothing about coping with the inevitable difficulties of life.
Acceptance
Helping patients become willing to face their difficult thoughts is the "acceptance" part of ACT. We might say, "Ok, you think you are fat and disgusting." Even though we do not agree with this thought and consider it harmful, we do not argue with or challenge it. Instead ACT uses mindfulness and cognitive defusion methods to help people mentally "step back" and see this thought for what it is: just a thought, i.e. the firing of certain synapses in the brain that may or may not be helpful. Eating disorder thoughts are mental constructions that have formed as a result of separate thoughts and events that have become associated and that are now triggered involuntarily and as if they were one. For example, therapists often hear how associations between feeling bad, not eating, and in some way feeling better or "in control" can be traced to an event such as this one:
"Right after he broke up with me he started dating the skinniest girl in our class. I felt so bad, I could hardly eat. When I started to lose weight it felt good when people complimented me. That"s when I started to restrict on purpose, and the more weight I lost the better I felt. It was like the one thing I could do to feel in control."
When thoughts are associated, separate thoughts and the impulses they bring up can become fused, as if they were one and the same. Thereafter, whenever any part of this thought is triggered, the entire ‘"fused thought" arises. For example, once eating behaviors have been associated with stress relief, any experience of angst may trigger an eating disorder thought like this: feeling anxious, can"t stand it, don"t eat, feel better. At this point, the world as colored by this thought seems so real, it"s as if the person is no longer interacting with thoughts at all. Instead eating/not eating has become a life or death reality.
Facing ED Thoughts
Just as getting out of quicksand requires a counter-intuitive action, facing eating disorder thoughts without obeying them can seem impossible. Yet it is the only alternative to being enslaved.Once they exist, eating disorder thoughts and impulses cannot be willfully stopped from arising. What is possible is to learn to look at thoughts instead of viewing the world from them.
Mindfulness is a two millennium-old method for creating this distance and objectivity. Mindfulness makes it possible to become aware that in any present moment there is a "me" that is thinking and a "me" that can "watch myself think." When patients first experience this, I often ask them, "Who is watching?" When they become curious about this observing self—a self that transcends their thinking mind—they can see that it is possible to view both their self and their thoughts within a bigger context than they previously knew, creating a space in which new possibilities can arise.
Research has documented that the perspective from which thoughts are viewed can significantly alter their impact. For example, a patient told me, "I can"t stand to feel full—it makes me feel like I will blow up!" When fused with this thought, it seemed literally true to her. From her perspective, eating until full was akin to annihilation! Using mindfulness she was able to learn to observe this thought instead of being caught in it, and it became possible for her to say "I"m having the thought that if I feel full I will explode."
In the space that opened she had room to feel sad that the years of eating only morsels in order to obey this thought had cost her many of her dreams. In her case, being a slave to eating disorder rules had forced her to withdraw from training as a potential Olympic skater. From this new vantage point she could begin to consider whether she might be willing to have this thought, and even tolerate the anxiety it evoked, if it meant she could begin to follow new dreams, such as becoming a skating teacher.
Connecting with an Ultimate Purpose
In line with this, another goal of ACT is helping patients to connect with their deepest values and ultimate purpose in life. What else could generate a willingness to face what torments us and to let go of behaviors that provide an illusion of control? By connecting with values, patients become aware of what they would want to be able to say about their life if their eating disorder thoughts and impulses were not controlling their actions: "In a world where you could choose to have your life be about something, what would you choose?" When patients feel immobilized on the difficult road to recovery, values clarification shines a compelling light on why they must go on.
ACT"s overall therapeutic goal is to help patients ride out the inevitable waves of emotionally-provocative thoughts and impulses while committing to actions that align with what really matters most in their lives. ACT is challenging because it conflicts with some of the basic tenets of Western thought, such as that "pain is bad," "happiness depends on feeling good ("feel-goodism")," and "if you just work hard enough you can get whatever you want." Therapists are hooked by these beliefs in ways that are not all that different from our patients—I know I have been. It has taken me time and practice to integrate ACT into my work. To apply it I must continually ask myself, "What do I do when faced with pain?"The results have been professionally and personally rewarding.
(Note: The Anorexia Workbook by Michelle Heffner and Georg Eifert is a good client resource utilizing ACT principles.)
About the Author
Kathy Kater, LICSW is a psychotherapist in St. Paul, MN who has specialized in treatment and prevention of the full spectrum of body image, eating, fitness and weight concerns for over 30 years. She is the author of the Healthy Body Image curriculum (2005, NEDA), and is passionate about promoting the Model for Healthy Body Image and Weight upon which that curriculum is based (more information at BodyImageHealth.org)
