Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) is the third generation of behavioral therapy, which expanded on earlier attempts to understand cognition and internal dysfunctions. Instead of actively trying to change the context and formal structure of an individual’s cognition, third-generation behavioral therapies emphasized the flexibility an individual experiences with their cognition. Developed by psychologist Steven Hayes, acceptance and commitment therapy targets an individual’s ability to make sense of external and internal stimuli they’re processing. For instance, “…he learned that thoughts could be viewed as hypotheses rather than literal truth; from radical behaviorism, he learned that all psychological events have effects based on their context.” (Sharf, p.623, 2008)
Relational frame theory (RFT) is the basis of ACT.
In this theory, language and the association’s individuals form with language make up a distinct part of an individual’s experience in the world. In his book World Hypotheses (1942), philosopher Stephen Pepper developed a philosophy to understand how an individual conceptualizes their relationship to the world based on the assumptions we make about the different criteria for what is knowledge and what is truth. When language is developed around stories (myths, morals, maxims, religious beliefs) as well as personal experience it also has an influence on an individual’s perception, responses and behavior. For instance, a woman who is afraid of conflict and perceives her boss as authoritative might have anxiety about asking for time off. Instead of targeting behaviors and changing them like more traditional behavior therapies, ACT looks to identify goals that will help the client to generate awareness and find acceptance with the abnormal experiences they’re living with. The goal of ACT is psychological flexibility, “meaning that ACT aims to train individuals to actively and openly contact their ongoing experiences in the present moment as fully conscious human beings, without defense and as it serves their chosen values.” (Sandoz, Wilson, DuFrene, p.17, 2011) Psychological flexibility is the ability to discover and develop the flexibility to interpreting their thoughts. This can include developing what is called “valued living.” In valued living, the individual discovers that living within their particular set of values and lifestyles will increase their overall happiness. In ACT, the development of psychological health is all about fostering and developing psychological flexibility. This is reflected in the idea that the phenomenon of psychopathology is a direct reflection of human suffering. From an ACT perspective, human suffering emerges from psychological processes, particularly those involving human language. Therefore, we cannot readily assume that all psychological suffering is a byproduct of diagnostic labels but just something we all experience in our lifetime.
ACT has six key processes including cognitive defusion, experiential acceptance, present moment focus, transcendent self-awareness, valued living.
Cognitive defusion “involves experiencing an event in its complexity without emotions or cognitions about the event dominating the experience. (Sandoz, Kelly, DuFrene, p.20, 2011) In more concrete terminology, cognitive defusion involves the ability to assess the nature of thoughts resulting in the ability to identify and let go of those that cause suffering. Take for example, a client whose manager corrects her for not getting to work on time and she experiences feelings of failure. Cognitive defusion would include assessing the thoughts and whether they are true, specifically whether being chastised for being late is equivalent to failure.
Experiential acceptance is the process of openly accepting an individual’s experiences without deeming them as positive or negative. It does not mean accepting the accompaniment of unpleasant experiences or not witnessing their experience but allowing them to be there without judgment or action to avoid further suffering.
In present-moment focus, the goal involves employing a flexibility in the perception of intra and interpersonal event. This means understanding the different things in an individual’s current cognition that are causing distractibility.
Transcendent self-awareness is the ability to experience flexibility in the way an individual perceives themselves. There is no over-arching or dominate aspects of one’s identity that makes it impossible for the individual to feel different sensations or things. It involves not letting certain experiences of the self, hinder an experience in the moment. Someone who is able to have transcendent self-awareness is able to be a boss at work, a partner to their spouse, and nurturer to their children.
In Valued Living, “valued living involves living in such a way as to facilitate contact with chosen values.” (Sandoz, Wilson, DuFrene, p.22, 2011) This means that values from an ACT perspective are congruent with an individual’s actions and behaviors that dominate the core of who the individual is. For example, a mother who is breastfeeding and experiencing post-partum depression might be experiencing thoughts and beliefs about her child that is not congruent with her value of being a loving mother. Focusing on the value of being a loving mother, while accepting that pain in motherhood is a normal example of incorporating valued living into treatment.
ACT Considerations for Eating Disorders and Anorexia
Eating disorders are exceptionally difficult to treat, especially amongst adult patients with a long-term history of the illness. Eating disorders tend to by symptoms of a complex ego system, with individuals who possess the disorder exhibiting extreme ambivalence to treatment. Inpatient or residential treatment is often needed to help regulate individuals with extreme symptoms and although these solutions can produce short-term improvements in the discourse on long-term improvements appears to be relatively low. “For adults with anorexia nervosa, there are currently no treatments that have achieved empirical support.” (Agras et al., 2004; Kaplan, 2002; G. T. Wilson, Grilo, & Vitousek, 2007). However, treatment for anorexia has seen strides in using cognitive therapies to help individuals with their thoughts and perceptions of their experiences with their bodies and eating. A growing body of research suggests that ACT methods such as experiential avoidance, hyper-awareness, and disordered values are central to the development and maintenance of eating disorders. Eating disorder difficulties are mapped out in terms of deficiencies in the 6 core processes of ACT including present-moment focus, cognitive defusion, experiential acceptance, transcendent self-awareness, valued living, and committed action. Treatment for anorexia looks to understand the avoidance, awareness and deficiencies of the 6 core components of well-being while increasing flexibility. “Experiential avoidance has been shown to be particularly high in eating disorder populations” (Cockell, Geller, & Linden, 2002; Keyser et al., 2009; Mizes & Arbitell, 1991; Orsillo & Batten, 2002), and it appears that eating disorder symptoms often function as a way to help the patient avoid upsetting internal experiences (Hayes & Pankey, 2002; Keyser et al., 2009; Paxton & Diggens, 1997; Serpell, Treasure, Teasdale, & Sullivan, 1999). Experiential avoidance represents an individual’s attempt to avoid certain thoughts, feelings, sensations or experiences related to their disordered eating. Individuals with eating disorders become very critically aware of their body and food intake as a means of controlling their external and internal environment. “Patients with eating disorders also tend to be less aware of their emotions than healthy individuals, which may make it more challenging for these patients to defuse from these internal experiences” (Merwin et al., 2011; Merwin, Zucker, Lacy, & Elliot, 2010). Research also points to the fact that individuals with eating disorders also show less regulation in emotional intelligence and poor personal awareness. Because of the emphasis placed on the eating disordered individuals weight, shape, and eating behavior, other areas of their life become neglected such as behaviors that maintain physiological and psychological well-being. “Patients with eating disorders also tend to have poor clarity for values unconnected with food and body image.“ (Fairburn, 2008) When it comes to addressing valued living, it is particularly difficult to motivate the eating disordered individuals to live from their personal values. This is because their values are skewed toward achievement on a specific body weight, shape and size. Acceptance and Commitment Therapy (ACT), is helpful because of its emphasis on taking committed action toward living within proper value domains and increasing greater psychological flexibility and tolerance for discomfort. According to Acceptance and Commitment Therapy for Eating Disorders, “From an ACT perspective, eating disorders are particular forms of psychological inflexibility.” (Sandoz, Wilson, Dufrene, p.24, 2011) In a practice used to help increase psychological flexibility in the book, “Living in Your Body and Other Things You Hate: How to Let Go of Your Struggle with Body Image Using Acceptance and Commitment Therapy,” the practitioner asks clients to take deep explorations into their inner-awareness through understanding their bodily sensations. Through guided visualizations and meditations that bring awareness to what the client is experiencing in the moment, they’re able to increase the client’s overall psychological flexibility by understanding and noticing their breath, how the body feels, bringing attention to different parts of the body, body scans and more. Through each sensation, the client is asked to breathe through any discomfort they’re feeling while accepting what it feels like to be connected to their bodies. An example of this looks like the following:
“And now let your awareness gently expand out and take in each of the physical experiences you are having right now, from the strongest to the most subtle. If you find your attention drawn into a single sensation, see if you can expand out from that sensation to take in the whole of your physical experience. See if you can let your attention hover there, on the whole, for use a moment.”
(Sandoz. p.61, 2014)
This is an example of how ACT can help increase an individual’s acceptance, present moment awareness, and transcendental self-awareness. Along with implementing mindfulness-based practices that help shift an individual’s tolerance for sensational experiences, ACT helps shape functional targets that help clients interact more effectively with the things in their lives that are causing distress, pain and intolerance. Clinicians also find it helpful to present opportunities for present-moment focus, “the present moment is where contingencies are being presented that can shape effective behavior.” (Sandoz, Wilson, Dufrene, p.24, 2011) This is what clinicians guide individuals through as present-moment awareness that helps implement more self-compassion for what the individual is experiencing. Much like understanding cognitive distortions, in cognitive behavioral therapy, creating acceptance and patience for an individual’s thought process is an integral part of helping achieve present moment focus. Many individuals suffering from eating disorders, struggle with cultivating acceptance for what is. A painful experience that happens in the individual’s life might cause excess suffering and rumination around rigid ways of thinking and behaving and how to avoid the pain in the future. Having control over their eating, the individual gains relief by imagining how she/ he might skip a meal in an attempt to control her weight loss. Using ACT in helping mitigate these thought cognitions is great for developing present-moment focus and accepting drawing attention to their thought processes in the present moment without complications of the future or past. Using present-moment awareness, allows the eating disordered individuals to leave their rigid focus on their body weight and focus on their present sensations in the moment. It is understood that present-moment focus, acceptance and self-awareness are not tools that should be ideally discounted in the therapeutic process. It is about generating presence for the things that are most meaningful for the eating disordered clients. Even though experiencing the sensations of the body can be especially challenging for eating disordered individuals it is important to cultivate in order to produce adequate change. However, this adequate change is documented through the process of valued living and committed action. In committed action, an example of a therapeutic intervention would look like the following:
“take a moment and list five situations in your life that are both meaningful to you and likely to get your awareness scattered or stuck. Now write two numbers between 1 and 10 next to each situation, representing how meaningful (M) and how challenging (C) that situation is for you, with 10 indicating that the situation is one of the most meaningful or challenging you’ve experienced and 1 indicating that the situation is one of the least meaningful or challenging you’ve experienced. “
(Sandoz. p.71, 2014)
After the individual identifies what has been a challenge for them about staying present and accepting their bodily sensations, they’re asked to make a commitment to living a life that is indicative of present body awareness. An example of this commitment might be noticing the way an individual’s shoe feels as she takes each step forward every morning on the way to school. This process is an example of how one might increase cognitive defusion while staying committed to living within their value system.
It is clear that Acceptance and Commitment Therapy is a great therapy to use for the treatment of eating disorders because of its 6 core processes that bring awareness and acceptance of intolerable suffering to the client.