Question 1

Can an ACT approach help address the high degree of conflict that often develops between youth with eating disorders and their caregiver who takes on a role of monitoring food intake?

Rhonda Merwin · Accepted Answer

Conflict may be minimized by using externalizing language (referring to the eating disorder as an entity separate and distinct from the individual, e.g., "It must be hard to eat when the ED is so loud…"). While common in other therapeutic approaches to EDs, in ACT, externalizing language has a central role as a form of defusion. Defusion separates the individual from their experience and allows for a more dispassionate observation of events.

ACT also emphasizes the function of behaviour, or how ED behaviour helps to alleviate the individual's immediate distress, even if it has other negative consequences or costs for personal values. Helping family members understand how the ED helps their loved one cope may reduce conflict. Family members may be better able to see rigidity around food or "ED flare ups" as a signal of suffering, and respond with warm but firm boundaries around the ED. They may be also better able to help the individual tolerate emotional discomfort in order to better meet their long-term physical and emotional needs.

ACT may also reduce conflict by helping the caregiver remain flexible and effective in the moment, guided by their own personal values, rather than "hooked" by painful thoughts and feelings (such as anxiety, sadness, frustration or desperation) and over- or under-responding to ED behaviour. An example of using ACT with parents/caregivers of adolescents with anorexia nervosa can be found here: Merwin et al., 2013; Timko et al., 2015). The ACT for Anorexia Nervosa book (Merwin, Zucker & Wilson, 2019) https://www.amazon.com/ACT-Anorexia-Nervosa-Guide-Clinicians/dp/1462540341, also has a chapter devoted to using ACT with family and caregivers of individuals with eating disorders.

See also Question 2 on addressing relationships damaged in the treatment process.

Question 2

For youth with eating disorders, recovery can include high levels of conflict with caregivers. Can ACT be used to address the relationships that can be damaged during the treatment process?

Rhonda Merwin · Accepted Answer

There are a number of other ways that ACT might address relationships damaged in the treatment process.

First, ACT focuses on values. Values may include acting with kindness, compassion, presence, genuineness, flexibility or love, among other examples. Clarifying values may help maintain or improve relationships. Individuals with eating disorders and their caregivers may use values as a "guiding light" – and commit to behaving consistently with those values even when it is most difficult (such as in a potentially high conflict situation)

Second, ACT focuses on openness to feelings. This includes being open to one's own feelings, as well as the feelings of others. ACT emphasizes that it is OK to feel, to express feelings, and to be genuine. This can help individuals better understand one another and increase closeness. ACT also emphasizes (and directly trains) flexible perspective taking. This enables an individual to see things from another person's perspective or from a more distant vantage point, allowing for greater clarity or more compassion for themselves or others.

Third, ACT emphasizes defusion from stories or narratives that are unhelpful. This includes narratives about what another person did or did not do. ACT encourages stepping back or "unhooking" from stories when they are not "unworkable" (i.e., not workable for a life well-lived or diminish life vitality).

The response to Question #1 provides additional information on using ACT to address the high degree of conflict between adolescents and caregivers.

Question 3

I don't work with disordered eating in my practice, but it does come up a lot in the history of clients' experiences.  Is there a specific way to inquire about eating disorders during intake for generalized therapy?

Rhonda Merwin · Accepted Answer

Practitioners often don't ask about eating disorders. This is unfortunate, given that these problems are relatively common and disturbed eating, lack of exercise etc., might be factors contributing to negative affect, lack of concentration or other presenting complaints. Simply asking someone about their eating and exercise behaviour, and the extent to which body weight influences their sense of personal value or worth might be enough to identify clinically relevant issues. However, individuals may be asked more specific questions regarding their typical eating patterns (whether they eat approximately 3 meals and 2 snacks/day or a 24 hour recall of dietary intake, or detailed questions about portions). Individuals may also be asked specifically about attempts to completely avoid certain foods (considered "forbidden" or "off limits"), have rules about eating, and whether they ever feel like they lose control over eating (whether or not they eat a large amount of food), as well as maladaptive weight control strategies (for example, explicitly asking about self-induced vomiting, or the use of diet pills, laxatives etc.). Inquiring about these problems is particularly important for individuals with chronic illnesses that increase their risk of EDs, such as type 1 diabetes, or with high risk factors (e.g., participation in particular sports etc.).

Question 4

Is it appropriate to help a person externalise the eating disorder voice and give it a separate name so that the person can differentiate between her own accepting voice and the judgmental voice of the disorder?

Rhonda Merwin · Accepted Answer

Absolutely. From an ACT perspective, this is an example of defusion. Defusion creates a separation between the self and the thoughts, feelings and body sensations that one might observe and encourages dispassionate observation of thoughts (as mental activity, rather than literal events). This degree of separation between the self and the ED, while potentially resisted (because the ED is ego syntonic or it is scary to let it go), ultimately creates the space needed for the individual to begin to sense themselves (their feelings and needs - and their personal values).

Additional strategies might also be suggested by ACT, including monitoring the ED volume (observing fluctuations in the intensity of eating or body-related thoughts/feelings and the context in which these fluctuations occur) and a number of other defusion and self-as-context exercises.

Question 5

What are the core ACT pathological processes that are often happening with eating disorders?

Rhonda Merwin · Accepted Answer

ACT formulates problems in living as the result of two inter-related sources of psychological inflexibility: cognitive fusion (i.e., overattachment to the content of mental activity that generates rigid ineffective behaviour) and experiential avoidance (i.e., unnecessary attempts to change form or frequency of unwanted internal experiences). A key difference between ACT and the traditional CBT approach to EDs is rather than try to change body-related thoughts, ACT aims to reduce overattachment to body-related thoughts/feelings and/or unnecessary attempts to avoid or escape these experiences (or the internal experiences that turned attention to the body in the first place, e.g., fear, self-loathing, self-disgust).

ACT addresses ED behaviour via engagement of core processes:

Acceptance - Opening up to feelings; allowing feelings as "guests in your home." This includes any and all feelings that might arise as a result of being a conscious human being with a history and in the moment of eating. With acceptance, there is less need to stuff, starve or purge feelings.

Fusion - Unhooking from narratives; noticing "thinking" or thoughts, and mental processes like judging, comparing, etc., with less attachment (or "buy in"). Defusion includes separating oneself from the ED more broadly (as a collection of thoughts/feelings) and from the rules it generates.

Present Moment Awareness – Being in the here and now (rather than the feared future or regretted past); disengaging from unhelpful mental activity (e.g., comparing, judging) to experience the world directly through the 5 senses; Individuals learn nonjudgmental awareness of experience as it unfolds, including hunger/satiety, the experience of nourishing the body, etc.

Self-as-Context – Taking the perspective of "the observer" rather than being overly defined by particular thoughts/feelings or outward appearances.

Values – Defining freely chosen qualities of purposeful action; Things other than thinness, perfectionism or control that are important to the individual; who they would want to be or how they would want to behave if they were not entangled with self-judgment, perceived expectations etc., and instead choosing actions based on personal meaning or life vitality.

These processes culminate into increased psychological flexibility, or the increased ability to remain in contact with unwanted internal experiences and engage in behaviour that is effective for the situation or consistent with deeply held personal values. These ideas are also elaborated in the attached.

Question 6

How would ACT help someone with an eating disorder who finds it overwhelming and uncomfortable to feel and be in their body and they spend a lot of time living in their mind?

Rhonda Merwin · Accepted Answer

Individuals with EDs (particularly those with restricting variants) often do find it overwhelming to feel and be in their body, and from an ACT perspective, this is the function of the ED. These individuals have retreated to the mind (and concrete rules for behaviour) to avoid/escape the more amorphous and uncontrollable elements of human experience. For individuals with anorexia nervosa, biological adaptations to starvation offer additional benefits in this regard, "quieting" the body.

Becoming aware of oneself may be a slow process. Some individuals with EDs may find it aversive to even be aware of their own breath. It can be helpful to start with a 5-senses experience of the world outside the skin (what can be felt, heard, seen, etc.), eventually allowing more awareness of internal experience. This exposure is titrated based on an individual's willingness and capacity. The idea of expanding the "window of tolerance" might be a useful conceptual frame. Over time, this work may shift from not only allowing feeling but also some appreciation for the information that feelings provide about what we need or what brings life vitality or joy. Willingness to allow feeling (or experience) is facilitated by creative hopelessness interventions. These ideas are also elaborated in the attached.

Question 7

Hi Rhonda, do you have advice for creating willingness with people presenting with restrictive type eating disorders who find that their restriction is working for them, eg., they are maintaining the body weight they want, they feel a sense of control, and their behaviors function to improve self-esteem? Thank you.

Rhonda Merwin · Accepted Answer

In ACT, there is a segment of work called creative hopelessness that creates readiness for change. Creative hopelessness refers to the experience of being "hopeless that avoidance/control can work" and "ready for a creative solution to their problem." In ACT, the creative solution is openness (or acceptance) of unwanted thoughts/feelings.

As you know, the reality is that the ED is working for a lot of things (it is both positively and negatively reinforced), and that is why it is so difficult to disrupt. From an ACT perspective, it is important to appreciate the "gifts" of the ED while also creating a context in which the individual can observe the unintended consequences or costs for personal values. 
Importantly, this is different than generating a pro/con list or talking about the future negative health consequences – it is densely experiential. Strategies aim to help the individual make experiential contact with how the ED limits their life now or how it is costing things that they care about.

For example, in ACT for Anorexia Nervosa (https://www.amazon.com/ACT-Anorexia-Nervosa-Guide-Clinicians/dp/1462540341), we outline several strategies with clinical dialogue to help the individual contact how "nothing is ever enough," the ED wants more; relief is temporary; distress returns with the next meal; or how despite their efforts, they may still feel badly about themselves etc. Strategies also specifically elevate the ways in which the ED limits their ability to be present and engaged with people or things that they care about (for example, how preoccupation with food/eating makes it difficult to really connect with other people during interactions or body concerns lead to avoidance of social situations).

Question 8

What is the main therapeutic goal of ACT in the treatment of eating disorders?

Rhonda Merwin · Accepted Answer

ACT targets psychological inflexibility in its many forms. This includes eating and weight related behaviours, as well as other topographically dissimilar behaviours that serve a similar function and are ineffective for the situation or inconsistent with deeply held personal values. For individuals with AN, for example, behaviour change targets include restrictive eating, overexercise, body comparisons, etc., as well people pleasing, conflict avoidance etc., that interfere with the individual getting their physical and emotional needs met or living a valued life. These other behaviours are considered part of a larger class of functional behaviour, of which maladaptive eating and weight control are only one element.

Ultimately, the goal of an ACT intervention is valued, vital living in the presence of any and all thoughts and feelings.

This is accomplished by disrupting rigid and reactive behaviour patterns of the ED and establishing new patterns of behaviour linked to personal values and incompatible with an ED.

It is also important to note that ACT is a behavioural intervention and is situated broadly under the CBT umbrella. Thus, behaviour change goals that are typical in CBT for EDs (e.g., meal planning, stimulus control strategies, etc.) are included in an ACT treatment.

Question 9

How would you respond to adolescents who frequently voice that they "feel fat" and aren't overly concerned about the objective reality of this statement?

Rhonda Merwin · Accepted Answer

In ACT, the truth of a thought is irrelevant and not targeted for change. Rather, the focus is on "workability of listening to the thought" and/or allowing it to determine/dictate action. i.e., What happens when you listen to that thought – does it take you where you want to go? Does it build your life out or narrow it down?

"Feeling fat" is also considered a "stand in" for deeper insecurities, fear or pain. In ACT, a typical response would be to speak to this deeper concern (if it is known), or identify the functional significance of thought/feeling, i.e., What are the conditions under which this feeling arises or is more or less intense? For example, perhaps this feeling is more intense at certain times of the day or in certain situations. What else is going on at those times? What else is the individual experiencing or avoiding experiencing by focusing on body weight? And what, if anything, does this tell you about what they need?

Question 10

Do you have key metaphors that you use when working with people with binge eating problems and other eating disorders?

Rhonda Merwin · Accepted Answer

I often use the metaphor of the "ED volume," particularly with EDs or maladaptive weight control. This metaphor helps individuals take an observer perspective and creates some space between the individual and the ED. It also helps identify the functional significance of ED symptoms by teaching the individuals to observe the broader emotional context when ED is "louder" (e.g., times when they are feeling lonely, ineffective etc.).
For all EDs, including BED, I use a Self-parenting metaphor. The idea is that when we are young, our caretakers provide for our needs. However, as we mature, it becomes our responsibility, and we have to decide how we will self-parent. I use Baumrind's work that specifies parenting approaches along 2 dimensions: (1) boundaries or expectations/demands and (2) warmth. The 4 emerging parenting "styles" may be thought of as self-parenting strategies (or approaches to managing oneself and one's own behaviour). Authoritarian (high expectations/boundaries and low warmth) is a rigid, rule-based and punitive approach. It focuses on obedience and punishment (many individuals with AN have this approach to managing themselves). Permissive (low expectations/boundaries, high warmth) parenting is limitless, with no or few boundaries. This is a metaphor for binge eating, and individuals with bulimia nervosa may be thought of as vacillating between Authoritarian and Permissive (self)parenting. Neglectful (low expectations/boundaries and low warmth) might also be a match for some individuals with EDs. In neglectful (self)parenting, the individual is absent or uninvolved in meeting their physical and emotional needs and have overall poor self-care. And finally, Authoritative (high expectations/boundaries, high warmth) (self)parenting is the approach that is most adaptive and the aim in ED treatment. It is a flexible, accepting, attuned approach to taking care of oneself and one's needs (it is also the parenting strategy with the best outcomes). This metaphor can be used throughout treatment to help the individual observe their own approach to managing (or caretaking) themselves and set a course for change. By likening the individual to a parent/caretaker, it might also be possible to evoke a behavioural repertoire of kindness, compassion, love or nurturing/support. This metaphor is woven throughout the ACT for Anorexia Nervosa book (https://www.amazon.com/ACT-Anorexia-Nervosa-Guide-Clinicians/dp/1462540341).

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