There are six core processes that are central to acceptance and commitment therapy (ACT): acceptance, cognitive defusion, present-moment awareness, self-as-context, values, and committed action. Growing evidence suggests that these processes counteract the development and maintenance of many, if not all, mental health issues by boosting psychological flexibility.
This article is an exploration of the six core processes and how they relate to therapy for eating disorders. Concepts within this article have been adapted from Mindfulness and Acceptance for Treating Eating Disorders and Weight Concerns.
Eating disorders are broadly considered to be coping mechanisms that develop as a way of avoiding distressing thoughts, feelings, and physical sensations. Experiential avoidance can occur around body- and food-specific internal experiences, such as fear of feeling fat or consuming specific foods. It can also occur around broader thoughts and feelings that promote poor self-esteem, such as feeling unlikeable or inadequate.
Research shows that experiential avoidance is particularly high among populations with eating disorders (Orsillo & Batten, 2002; Wildes, Ringham, & Marcus, 2010). Specifically, mood intolerance has been shown to predict both dietary restriction (Merwin, Timko et al., 2010) and binge eating (Hayaki, 2009).
Because eating disorders function as a means of avoiding unpleasant internal experiences, the ACT emphasis on observing and relaxing resistance to (accepting) the full spectrum of thoughts and emotions makes it a natural approach to helping this population.
Cognitive fusion is the process in which an individual identifies with their thoughts to the point of fully believing them to be true.
It is common for individuals with eating disorders to be highly fused with distressing thoughts about the self. Such thoughts may include evaluations of one’s worthiness, success, or lovability. Engaging in disordered eating behaviors (e.g., restricting calorie intake) becomes a way to locate self-worth in self-control (e.g., I feel successful when I am controlling my weight.)
Defusion is the process of disarming self-destructive beliefs by taking the perspective that the self is not the content of its thoughts. The self is, instead, viewed as the one who is visited by thoughts. Defusion guides the client away from a self-as-content perspective to a self-as-context perspective.
Part of what makes eating disorders so difficult to treat is that the disordered beliefs are closely entwined with one’s sense of self. Individuals with eating disorders tend to not only view their disorder as a part of who they are, but they may also value it and feel reluctant to “give it up.” Without it, they may lack identity. This makes recovery especially challenging, since we tend to behave in ways that maintain our sense of self, even when those behaviors are misaligned with our values.
Strengthening a sense of self that is apart from thoughts related to the eating disorder builds a contextual self in which thoughts and feelings related to the eating disorder are nonessential to one’s self conception.
Present-moment awareness refers to a state of active, open attention to the present and the ability to mindfully observe thoughts and feelings at a distance without judging or owning them.
People with eating disorders often have a hard time identifying their emotions (also known as alexithymia), making it difficult to defuse from them. As eating disorder behaviors become more habitual, awareness of what is driving them decreases. Present-moment awareness draws attention to this nearly automatic process of reacting to unpleasant thoughts and body signals.
Values and Committed Action
When body shape and weight are valued at the expense of other important values, life balance suffers. An individual with an eating disorder may, for instance, avoid family activities because they involve food. Their grades in school may suffer because their time is dominated by exercise and body obsessions. Often without conscious awareness, body image concerns are increasingly overvalued and other life values become lower priorities.
A lack of values clarity can lead those with an eating disorder to be ambivalent about treatment and disinterested in engaging more with other areas of life. Acknowledging central values that have been sacrificed and recommitting to them can provide the motivation needed to fuel all aspects of recovery.
Conclusion: ACT Works
Again, eating disorders have been difficult to treat for many years because individuals closely link their disorder to their identities. ACT is an effective treatment for eating disorders because it encourages a more flexible and inclusive sense of self that is anchored in the life-affirming direction of one’s values. As described in this article, the six core ACT processes are effective tools for applying ACT to your client’s eating disorder.
Hayaki, J. (2009). Negative reinforcement eating expectancies, emotion dysregulation, and symptoms of bulimia nervosa. International Journal of Eating Disorders, 42, 552–556.
Juarascio, A., Manasse, S., Espel, H. (2017). Acceptance and Commitment Therapy for Anorexia Nervosa and Bulimia. Mindfulness and Acceptance for Treating Eating Disorders and Weight Concerns. Oakland: Context Press.
Merwin, R. M., Timko, C. A., Moskovich, A. A., Ingle, K. K., Bulik, C. M., & Zucker, N. L. (2010). Psychological inflexibility and symptom expression in anorexia nervosa. Eating Disorders, 19, 62–82.
Orsillo, S. M., & Batten, S. V. (2002). ACT as treatment of a disorder of excessive control: Anorexia. Cognitive and Behavioral Practice, 9, 253–259.
Wildes, J. E., Ringham, R. M., & Marcus, M. D. (2010). Emotion avoidance in patients with anorexia nervosa: Initial test of a functional model. International Journal of Eating Disorders, 43, 398–404.