Journal of Contextual Behavioral Science 2 (2013) 85–94

Contents lists available at ScienceDirect

Journal of Contextual Behavioral Science

In Practice: Applications of Contextual Behavioral Science

Acceptance and Commitment Therapy for eating disorders: Clinical

art ic l e i nf o a b s t r a c t

Article history: Eating disorders, particularly among adult patients with a long course of illness, are exceptionally
Received 13 March 2013 difficult to treat. The few existing empirically supported treatments for adult patients with bulimia
Received in revised form nervosa do not lead to symptom remission for a large portion of patients. For adults with anorexia
22 July 2013
nervosa there are currently no empirically supported treatments. A small but growing body of research
Accepted 20 August 2013
indicates that Acceptance and Commitment Therapy (ACT) may be an effective treatment option for
patients with eating disorders. Despite the promise of this approach, there are at present no established
Keywords: protocols with empirical support for an ACT-based treatment for adults with an eating disorder. The goal
Acceptance and Commitment Therapy of the current paper is to describe the development of a semi-structured group-based treatment for
Eating disorders
eating disorders, discuss the structure of the manual and how we adapted standard ACT treatment
strategies for use with an eating disorder population, and to discuss clinical strategies for successfully
implementing the intervention. A brief summary of preliminary results of the program support the
acceptability and efficacy of this novel treatment approach.
& 2013 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.

1. Treatment of eating disorders approaches for eating disorders suggests that there is significant
room for improvement in terms of both treatment acceptability
Eating disorders are among the most challenging of psychiatric and efficacy.
disorders to treat (Fairburn, 2008; NICE, 2004). Although standard
cognitive behavioral therapy (CBT-BN; Fairburn, Marcus, & Wilson,
1993) and Enhanced Cognitive Behavioral Therapy (CBT-E; 2. Acceptance and Commitment Therapy for eating disorders
Fairburn, 2008) are currently the treatments of choice for bulimia
nervosa (BN) and binge eating disorder (BED), a large subset of A series of theoretical papers have been published suggesting
individuals (30–50%) remain partially or fully symptomatic at that Acceptance and Commitment Therapy (ACT) might be a
post-treatment (Brownley, Berkman, & Sedway, 2007; Fairburn particularly beneficial treatment for eating pathology (Hayes &
et al. 2009; Mitchell, Devlin, & de Zwann, 2008; Wilson, 2005). For Pankey, 2002; Heffner & Eifert, 2004; Heffner, Sperry, Eifert, &
adults with Anorexia Nervosa (AN), there currently exist no Detweiler, 2002; Manlick, Cochran, & Koon, 2013; Merwin et al.,
empirically supported treatments, despite the fact that a variety 2011; Merwin & Wilson, 2009; Orsillo & Batten, 2002), and a
of CBT and non-CBT based treatments have been evaluated (Byrne, growing body of research indicates that that factors targeted by
Fursland, Allen, & Watson, 2011; Hay, 2013; Touyz et al., 2013; ACT are highly relevant among adults with an eating disorder.
Watson & Bulik, 2012; Wild et al., 2009; Wilson, Grilo, & Vitousek, Many of these variables appear to be temperamental features that
2007; Yu et al. 2011). A recent study of CBT-E for underweight pre-date illness onset among patients with an eating disorder, and
patients found that only 60% agreed to start treatment, and of a growing movement seeks to better address these characteristics
those, only 60% demonstrated a clinically significant response in treatment (Zucker, Herzog, Moskovitch, Merwin, & Lin, 2011).
(Fairburn et al., 2009). The lack of success of extant treatment A number of small pilot studies assessing acceptance-based
behavioral approaches for eating pathology have demonstrated
promise for the treatment of eating disorders (Anderson &
n
Corresponding author. Tel.: þ 1 443 801 8093.
Simmons, 2008; Kristeller, Baer, & Quillian-Wolever, 2006; Safer,
E-mail address: [email protected] (A. Juarascio). Telch, & Chen, 2009; Wade, Treasure, & Schmidt, 2011; Wildes &
URL: http://www.contextualscience.org (A. Juarascio). Marcus, 2010). Preliminary data are likewise emerging for ACT

2212-1447/$ - see front matter & 2013 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcbs.2013.08.001
86 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94

Table 1
Session outlines and descriptions of modifications to commonly used ACT-techniques.

Topic Citationn Description/Modifications

Session 1
Homework review and introduction to ACT model n/a
Human suffering is universal p. 10
The suffering inventory p. 12
If the pain were gone… p. 14
Control strategies (Creative hopelessness) p. 33
Tug of war with a monster p. 32
“Dropping the rope” and eating symptoms n/a We extended the discussion of the tug of war metaphor, focusing on the use of
eating symptoms (restricting, binging, purging, etc.) as a way to control or
avoid distressing thoughts and feelings, and applying the concept of “dropping
the rope” to these behaviors, and emphasizing that stepping back from the
struggle to control these thoughts and feelings through disordered behaviors
frees up resources to engage in behaviors consistent with other life values.
Homework: p. 27 Patients were asked to think of a value-based goal that they could complete
Record daily coping strategies and rate how well they before the next session. They were asked to notice distressing thoughts or
work in the short and long-term. feelings that arise in pursuing the goal, and to apply the metaphor of
Practice “dropping the rope.” “dropping the rope” to continue working on goal in spite of their presence.

Session 2
Homework review and introduction to ACT model n/a
Quicksand and willingness p. 3
What is willingness? p. 125
Being willingly out of breath p. 49
Urge surfing Bowen, Chala, and Discussion of the use of willingness and “urge surfing”, particularly
Marlatt, (2010) in situations involving strong urges about eating (e.g. the urge to eat or binge,
the urge to restrict, the urge to use food rituals).
Willingness and following a meal plan n/a Discussion of the importance of normalizing eating to both decreasing eating
symptoms and the ability to pursue other valued goals. Discussed using
willingness to confront barriers (upsetting thoughts, feelings and bodily
sensations) that patients struggle with in attempting to follow a meal plan.
Short-term mind versus long-term mind and the Discussion of using willingness to make decisions from your “long-term mind”
relation to eating disorder symptoms based on valued directions instead of your “short-term mind” which often
urges you towards whatever decision causes the least pain or most pleasure in
the short-term regardless of its long-term consequences.
Yellow glasses p. 75
Homework: Activity guided patients to identify and observe experiencing an urge without
Urge surfing practice. reacting to it.
Practice willingness when following your meal plan. Activity guided patients to use willingness strategies to complete a challenging
meal or snack (e.g. choosing a feared food, completing a greater percentage of
the meal) in spite of the presence of distressing thoughts, feelings, or bodily
sensations.

Session 3
Homework review and Introduction to ACT model n/a
The polygraph machine p. 30
Epitaph exercise p. 166 Noted how patients did not report wanting to be remembered for maladaptive
behaviors such as, “Being really good at controlling her eating” or “Being really
thin”.
Get off your “buts” exercise p. 84
Cognitive defusion and “feeling” fat n/a Feeling fat is often perceived by the mind as the same as being fat (it's a
thought that feels really true). Instead of automatically buying into “feeling
fat,” we can treat it as any other thought and use defusion techniques.
Be where you are/Mindfulness p. 107
Homework The Reasons as Causes handout is an exercise in which a patient examines his/
“Reasons as Causes” worksheet her reason-giving and evaluates their effects on behavior. It illustrates the
importance of not allowing reasons (i.e., verbal constructs) to dictate behavior.
Practice using cognitive defusion. Patients were asked to practice using cognitive defusion. when “feeling” fat
and with other distressing thoughts.

Session 4
Homework review and Introduction to ACT model n/a
Snake phobia p. 36
Values mountain p. 161
Defusion and picking up a pen Bach (2005)
Mindful eating p. 110
Homework p. 112 Patients were instructed to eat a meal or snack mindfully and record their
Mindful eating experience.

Session 5
Homework review and Introduction to ACT model n/a
The volleyball game Eifert and Forsyth
(2005)
Passengers on the bus p. 153
Willingness to reduce dietary restriction n/a Discussion of dietary restriction as potentially reinforcing in the short-term,
but problematic in the long-term. Discussed using willingness to reduce
restriction in spite of distress that may arise in doing so.
Values p. 154
 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94 87

Table 1 (continued )

Topic Citationn Description/Modifications

Liminal eating Wilson (2008) Exercise taken from Contextual Science listserve discussion: http://www.
contextualpsychology.org/node/3474.
Homework Patients were asked to notice ways they may still be trying to restrict (e.g.
Practice reducing dietary restriction hiding food, choosing low calories options) and challenge themselves to be
willing to experience the discomfort that comes with not restricting.
Mindfulness Meditation Patients were asked to practice mindfulness meditation for a minimum of two
2-minute sittings, record their experiences/observations.

Session 6
Homework review and Introduction to ACT model n/a
Automatic word associations p. 73
Storytelling Harris (2008)
Fat, fat, fat p. 71 Modification of “milk, milk, milk”
Thank your mind p. 83
Pattern smashing p. 189
Value cards n/a Patients were given 1–3 cards (depending on group size) each listing a valued
domain, and asked to write about their own values related to that area on the
reverse side, then share at least one value with the group.
Homework Participants were asked to challenge themselves by breaking up a eating or
Pattern smashing body-image related pattern, and observe their experience and thoughts as
they did so.
Practice using cognitive defusion Patients were asked to practice using cognitive defusion, particularly with
disorder-related thoughts.

Session 7
Homework review and Introduction to ACT model n/a
Yellow jeep/chocolate cake p. 24
Cranky Aunt Ida p. 125
Willingness and body checking/avoidance n/a Psychoeducation about body checking and avoidance. Both may provide short-
term relief but increase weight/shape concerns in the long run. Discussed use
of mindful awareness to observe one's whole body, rather than scrutinizing a
specific part or aspect.
Leaves on a stream p. 76
Body exposure n/a Participants were asked to look at or imagine looking at a part of their body
that they usually would either avoid or check. They were asked to observe this
part fully, noticing if they were focusing particularly on aspects that they
disliked and redirecting their attention to noticing all features present. They
were also asked to nonjudgmentally observe the thoughts and feelings that
arose during the exercise and remain in contact with the image in spite of any
distress.
Homework p. 170 Participants were asked to engage in a body image exposure that would be
Ten valued domains worksheet challenging for them (e.g. avoid body checking, wear form-fitting clothes).
Body image exposure They were asked to mindfully observe the thoughts and feelings that arise and
practice defusing from judgments and evaluations.

Session 8
Homework review and Introduction to ACT model n/a
My values pie chart Fairburn (2008) Patients created two pie-charts, the first showing the percent of their time and
effort that is currently being devoted to different valued domains (including
weigh/shape and eating which dominated in many individuals first pie-chart).
They were then asked to create a second pie chart showing the relative
importance of valued domains and discussed using the pie chart as a guide for
how much time and effort they should spend on these areas. We also included
an open discussion of whether categories like weight and shape should be
featured in the second pie chart.
Chinese finger trap p. 37
Two radio dials p. 134
Hands in front of face p. 71
Eating a single chocolate n/a Patients were asked to write down all of the negative thoughts that might
arise while eating a single chocolate (e.g. thoughts urging them to binge,
restrict, or purge, fears of weight gain, etc.). They then were paired with a
partner and each took turns eating a single chocolate while the partner read
their “thoughts” aloud to them.
Homework Participants were asked to commit to be willing to experience a certain
Willingness in the service of values distressing thoughts or feeling in order to engage in a valued behavior, then to
engage in that behavior before the next session and record their experience.

n
The “Citations” column provides a source for obtaining a full description of the activity or exercise. Although many of these exercises are referenced in numerous ACT
resources, we have chosen to refer the reader to Hayes and Smith (2005), wherever possible due to its user-friendly nature. Citation page numbers refer to this source unless
otherwise specified. The full treatment manual and all associated worksheets are available at contextualscience.org.

specifically (Berman, Boutelle, & Crow, 2009; Juarascio, Forman, & concerns have been published (Eifert & Timko, 2012; Heffner &
Herbert, 2010; Merwin, Zucker, & Timko, 2012). Several books Eifert, 2004; Pearson, Heffner, & Follette, 2010; Sandoz, Wilson, &
detailing ACT-based treatments for eating disorders and related Dufrene, 2011); however, no data supporting the efficacy of these
88 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94

treatments are available. Despite the promise of this approach, includes educational information, experiential exercises, and
there are at present no established protocols with empirical sup- homework assignments designed to encourage patients to utilize
port for an ACT-based treatment for adults with an eating disorder. the strategies outside of the group time. Although each session can
The goal of this paper is to describe the development of a stand alone, the sessions are also designed to work in conjunction
group-based treatment for eating disorders, discuss the structure with one another to build on ACT skills each week. To facilitate
of the manual and how we adapted standard ACT treatment this, patients new to the group are encouraged to participate in the
strategies for use with an eating disorder population, and to discussion of the previous week's homework and session content
discuss clinical strategies for successfully implementing the inter- that occurs at the beginning of each session by bringing in relevant
vention. An empirical paper reporting initial results of the pro- examples from their own experience. Furthermore, other patients
gram described here was recently published (Juarascio et al. 2013), can be encouraged to use information learned in previous sessions
and a brief summary of the primary findings of that study are to help orient new members. The group facilitator can help any
discussed below. group members who report difficulty with the exercises problem
solve what they could have done differently, and encourage
patients to continue practicing the skills even if they were not
3. Developing an ACT-based group treatment initially successful. The homework review comprises approxi-
mately 15 min at the beginning of each group. After homework
Given that there are currently no empirically supported ACT is reviewed, the subsequent 60 min of the group consists of new
manuals for adult eating disorders, we developed and evaluated a material, exercises, and discussions.
manualized group treatment for this population. The manual was
designed to be used in the context of a residential treatment
facility for eating disorders, wherein patients ranged widely in age, 6. Treatment components
motivation for treatment, presenting diagnosis, and co-morbid
diagnoses. We decided to create a group treatment for use in an Below we discuss several of the primary treatment components
intensive treatment program because of the high utilization of and how they were adapted to focus on eating pathology.
inpatient treatment, residential treatment, and intensive outpati- Throughout, it is important to keep in mind that the main
ent programs among patients with eating disorders (Bowers, therapeutic goal of ACT is to promote psychological flexibility,
Andersen, & Evans, 2008). The development of effective treatment i.e., the ability to persist or change behaviors in the pursuit of goals
groups in residential or inpatient settings is therefore warranted. and values even when doing so brings a person into contact with
Although the present program was designed for use in a residen- aversive internal experiences (Hayes, Barnes-Holmes, & Wilson,
tial program, the manual can be easily adapted for other treatment 2012; Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013;
modalities. Hayes, Villatte, Levin, & Hildebrandt, 2011). Therefore, symptom
reduction, especially of internal experiences such as distressing
thoughts about the body, urges to binge, or feeling anxious or
4. Manual development
depressed, is de-emphasized in our treatment, with the focus
instead on helping patients live a more valued life. In order to
The treatment manual was based on several well-known ACT
promote therapeutic improvement, the manual targets six psy-
sources such as Acceptance and Commitment Therapy: An Experi-
chological processes (acceptance, defusion, present-moment
ential Approach to Behavior Change (Hayes, Strosahl, & Wilson,
awareness, self-as-context, values, and behavioral commitment)
1999, 2012) and Get Out of Your Mind and Into Your Life (Hayes &
that can together promote psychological flexibility. The six pro-
Smith, 2005). Exercises and discussions were drawn from these
cesses can in turn be summarized into three main targets of ACT:
sources and then tailored to address eating disorder symptoms.
being open (acceptance and defusion), centered (present-moment
Three initial waves of ACT groups were conducted at the residen-
awareness and self-as-context), and engaged (values and beha-
tial facility and edits to the manual were made iteratively follow-
vioral commitments). The overarching goal of psychological flex-
ing each round. For example, the manual initially contained fewer
ibility calls for patients to be actively engaged in their valued
experiential exercises, but after receiving positive feedback on
pursuits, which is facilitated by being open to internal experiences
these exercises from patients and witnessing increased engage-
and centered in the here-and-now. Each of these six processes can
ment in treatment following participation in the exercises in the
be viewed as belonging to a continuum, with the goal of the
first round of groups, the manual was modified to increase the
treatment to move from the pathological end of the spectrum
focus on experiential exercises.
(dominance of the conceptualized past or future, cognitive fusion,
experiential avoidance, attachment of the conceptualized self, lack
5. Manual overview of values clarity/contact, unworkable action) to psychological
flexibility.
The final treatment manual consists of eight, 75-min group
sessions. An outline of the exercises and metaphors used in each of 6.1. Experiential acceptance
the eight sessions can be found in Table 1. Although the manual
can be easily adapted for a different type of treatment program or Consistent with an ACT conceptualization (Heffner & Eifert,
in an outpatient setting, it was designed to complement an 2004; Sandoz et al., 2011), eating disordered behaviors are con-
existing residential treatment program and not to serve as a strued broadly throughout the treatment as coping mechanisms
stand-alone treatment for eating disorders. The manual is struc- that have developed to serve the function of helping individuals
tured in an open group format to allow new patients to join the avoid distressing thoughts, feelings, and sensations. Experiential
group at any time. Each session is designed to serve as a free- avoidance is conceptualized as occurring both around body and
standing intervention in which the overall ACT model is discussed food-specific internal experiences and also around broader dis-
and implemented. Thus, each session addresses core ACT princi- tressing thoughts (e.g. “No one likes me” or “I′ll never be good
ples such as developing openness to an acceptance perspective, enough”) and feelings (e.g. anxiety, depression, boredom, anger).
fostering a willingness to accept distress, teaching defusion from Discussions, metaphors, and guided practices are used to help
thoughts and feelings, and clarifying life values. Every session also patients connect their eating disorder behaviors to the desire to
 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94 89

avoid certain uncomfortable thoughts, feelings, and bodily sensa- distressing thoughts and feelings. In our experience, many patients
tions (i.e., experiential avoidance). An overarching goal of the ACT reported that they distracted themselves throughout meals and
groups is therefore to increase psychological flexibility, and in would do whatever they could to avoid experiencing the taste of
particular to decouple the link between distressing experiences their food or the thoughts that occurred as they ate. The novel
and maladaptive behavior, and to increase willingness to experi- experience of being aware of and defusing from thoughts
ence distress in the service of behavior change. During the groups, prompted many patients to challenge themselves to practice
the types of distressing internal experiences targeted include eating more mindfully during meals.
eating disorder-specific thoughts, feelings, and urges and other
thoughts and feelings related to depression, anxiety, interpersonal
difficulties, family concerns, and trouble at school or work. 6.4. Willingness
Exercises such as the Chinese Finger Trap Metaphor (Hayes et al.,
2012) are employed to show how eating disordered behaviors that Throughout the treatment approach, acceptance, defusion, and
temporarily allow patients to avoid emotions such as anxiety or awareness are taught to patients as skills that increase willingness
boredom actually worsen the experience of these thoughts and to make behavioral choices consistent with living a more valued
exacerbate symptoms. By actually “pushing” into these thoughts life despite distressing internal experiences during the recovery
and fully experiencing them, patients can choose behaviors process (Hayes et al., 2012). Willingness is described as an active
inconsistent with the eating disordered thoughts without first behavior, and exercises focused both on distressing food and body-
having to change the thoughts themselves. related experience (e.g., wearing a tight outfit for patients with
AN) and on broader behaviors connected with values (e.g., being
6.2. Defusion more open in family therapy, resisting urges to isolate oneself at
the treatment facility). For example, eating exposure exercises
The manual also focuses heavily on helping patients learn to allowed patients to practice willingly eating challenging foods,
defuse, or achieve psychological distance, from their thoughts, despite the presence of negative thoughts and feelings. Will-
feelings, and urges. We found that patients often reported trying ingness exercises also comprise a large number of the homework
to make unpleasant thoughts about their body “go away” by assignments, with goals such as choosing more difficult foods
engaging in a number of maladaptive behaviors including dis- during snack, reducing body checking, and engaging in other
ordered eating. Therapists used this opportunity to help patients difficult behaviors connected with broader values.
realize that efforts to eliminate or avoid these types of thoughts
are rarely effective in the long-term and often paradoxically
worsen body-related distress. Exercises such as a modification of 6.5. Self-as-context
the “Milk, Milk, Milk” exercise described in Hayes and Smith
(2005, p. 71), in which patients instead repeat the word “fat” over Eating disorders are notoriously difficult to treat, in part
and over again, provided powerful demonstrations that the emo- because the disorder feels like an essential part of the self
tional associations of words and thoughts are “accidental” pro- (Schmidt & Treasure, 2006). Although not surprising given the
ducts of one's learning history, and that one can learn to ego-syntonic nature of eating disorders and the variety of func-
experience these associations in a new way, such that they need tions that such behavior can serve, this strong attachment to the
not be eliminated nor determinative of behavior. Defusion exer- disorder is problematic. During our groups, patients often reported
cises were also applied to non-body or food related distressing reluctance to give up their disorder because it is part of “who they
thoughts that might similarly impair the patient's ability to make were as a person” and they were unsure who they might be
flexible behavioral choices (e.g. “No one likes me” leading to without the disorder. This problematic attachment to a concep-
avoidance of intimate relationships). Ultimately, we found that tualized self-image can make recovery challenging. Patients
increased defusion or distance from thoughts could increase tended to behave in ways that maintained this sense of self, even
flexibility in the presence of difficult thoughts and feelings and when doing so led to problematic behaviors and values-
allowed patients to more effectively pursue value-consistent inconsistent action. Throughout the group, therapists used a
behavior. variety of activities that helped patients more directly connect to
the “observer self,” or a sense of self that can have a variety of
6.3. Awareness thoughts and feelings without allowing these internal experiences
to define who one is as a person or how one should behave. Many
Consistent with previous reports (e.g., Frank et al., 2012; of the activities described above that are designed to foster
Harrison, Sullivan, Tchanturia, & Treasure, 2009; Merwin et al., experiential acceptance and defusion simultaneously function as
2011; Zucker et al., 2007), patients in our groups had trouble activities that promote this contextual sense of the observing self,
reporting their thoughts or feelings and alexithymia was com- which is also known as “self-as-context.” For example, any activity
monly noted. Mindful awareness is incorporated in to the treat- that promoted an ability to obtain distance from thoughts also
ment approach as a necessary precursor to accepting thoughts and helped the patient be able to see herself as someone separate from
feelings. Awareness is also connected to values, and patients were her eating-related thoughts, feelings, and urges. Additionally,
taught how to articulate their personal values and bring an activities focused on values clarification also promoted this parti-
awareness of these values into the present moment in order to cular sense of self as patients began to develop the sense that they
better allow values to guide behavior. Patients were also taught were complete individuals who are distinct from their eating
mindful eating during practice exercises conducted during groups disorder. By seeing where they hope their life to be going, and
(Segal, Williams, & Teasdale, 2002). Afterwards therapists led a how it contrasts with where they were now, patients were able to
discussion about the function of this activity, i.e., becoming aware gain perspective towards a self that is broader than the eating
of the distressing thoughts brought on by eating outside of the disorder and more able to engage flexibly in a variety of behaviors.
meal plan and being willing to allow those thoughts to be there The focus of our treatment on long-term goals and broader
while continuing to engage in the exercise. Throughout these behavior change maps closely onto a growing body of work
discussions, patients were encouraged to examine how increased supporting a long-term approach in the treatment of chronic
mindfulness allowed them to better defuse from and accept eating disorders (Touyz et al., 2013; Waller, Evans, & Pugh, 2013).
90 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94

6.6. Values and committed action passengers on the bus while one patient acts as the driver allowed
patients to experience the metaphor in a more encompassing way
The ultimate goal of increasing willingness is to foster flex- than one might by just presenting the metaphor in a therapy
ibility in the patient's behavior so that she can behave consistently session. We found that the more interactive we made the group
with her chosen values, rather than becoming locked into a sessions, the more engaged patients were during treatment.
pattern of behavior that is maintained by the desire to avoid Experiential exercises that utilized the full group were often the
distress and remain consistent with a conceptualized self-image. best way to ensure engagement. An additional example of how we
The end result is a more valued and meaningful life. We found that utilized the group to facilitate treatment is encouraging patients to
fostering committed action was highly relevant for the patients in explore the function of each other's behavior during group. For
our groups, as many reported poor ability to engage in behaviors example, if a patient refused to do a food exposure or switched the
consistent with their values and many others lacked clarity with topic away from a sensitive area, we encouraged group members
respect to any values aside from those related to their disorder. to gently point out these subtle avoidance behaviors and encou-
The exercises in our treatment manual attempt to increase rage the patient to explore the thoughts and feelings leading to
patients' clarity about what it is they truly value, examine the avoidance. We found that when group members noted this
ways in which the eating disorder conflicts with these values, and behavior in each other, the patient was less resistant than when
help patients begin to take concrete steps toward behaving it was the therapist who was pointing out avoidance patterns.
consistently with valued areas of life. In some sessions, patients Additionally, group members also encouraged each other to be
were asked how their lives would be different if they did not have willing to try challenging exposures and the experience of seeing
an eating disorder (or other concerns such as depression or other group member's engaged in the same behaviors facilitated
anxiety). This helped patients begin to explore what life domains willingness. Although we were initially concerned about negative
they might want to re-incorporate into their lives. In other peer pressure, we found this to be rare and noticed that most
sessions, patients were asked specifically about their values in patients were supportive of each other's progress in treatment.
specific domains or were asked to complete a valued domain
questionnaire to help clarify and increase mindfulness awareness 7.2. Open group format
of values. Therapists encouraged patients to write down a list of
their most important values to keep with them throughout The residential treatment setting in which this program was
treatment and review during challenging moments. Therapists developed necessarily shaped the manual in several ways. Because
also asked patients to develop value-consistent goals. We sug- patients are admitted to the facility on a rolling basis and are
gested that patients set up weekly check-ins with themselves to sometimes not able to attend all ACT groups available during their
regularly examine their behaviors and ask questions such as “Have stay, each group was designed as a stand-alone session that
my actions this past week taken me closer to or farther away from included multiple core ACT principles. Application of the program
my values?” and “ What could I do differently next week to remain in a different treatment setting may require modifications. For
more consistent with my long-term goals?” Values work also example, if using the manual in an outpatient closed group, it may
provides a context for the other ACT strategies, and therapists be preferable to structure the program so that each group focuses
emphasized that increased willingness to live with distressing on a more limited range of topics and builds on each other rather
thoughts and emotions served a larger purpose in that it affords than having each group focus on a larger number of ACT princi-
the opportunity to make progress in areas of one's life that provide ples. However, in some ways, we found that the open-group and
meaning and personal fulfillment. rolling admission was useful in maintaining a positive group
dynamic. For example, group members who had been to a number
6.7. Homework of ACT sessions were often more likely to engage in difficult
exposures and encourage others in the group to participate, which
Our treatment approach assigns homework at the end of every provided a useful opportunity for new members to see the
session to encourage utilization of the treatment strategies outside benefits of engaging in challenging values-consistent activities.
of group; worksheets describing the assignment and providing Additionally, patients who were further along in treatment had
prompts for recording of experiences are provided in the manual. already learned many of the ACT skills and were able to facilitate
Assignments are primarily focused on practicing ACT skills within newer members learning the skills more quickly. As mentioned
the context of accomplishing a challenging behavioral goal. above, we found that patients often responded better to group
Whereas some goals focus specifically on increasing eating flex- members rather than therapists noting maladaptive avoidance
ibility or decreasing body checking or avoidance, other assign- behaviors, fusion, or attachment to the conceptualized self. Having
ments allow patients to set their own goals based on their chosen advanced group members provided valuable opportunities for
values. Patients were instructed to bring their worksheets to the positive peer-based learning that was well-suited to undermining
following group, and homework assignments from the previous treatment resistance.
group session were reviewed as described above.
7.3. Diagnostic sub-groups

7. Practical tips for using the manual The manual was designed to be a transdiagnostic treatment
manual, consistent with the transdiagnostic CBT approach devel-
7.1. Utilizing the group oped by Fairburn, for use with patients with a variety of eating
disorders (Fairburn, 2008). Functionally, eating disordered beha-
We found that group treatment is well suited to an ACT viors are often more similar than different, with most functioning
approach and allowed our therapists to utilize the group in ACT- to relieve or otherwise avoid distressing thoughts or feelings.
consistent ways to improve comprehension and acceptability of However, despite the transdiagnostic nature of the manual, we
the treatment. For example, we often utilized the group to enact found it beneficial to separate patients into groups primarily
metaphors and exercises experientially. The “Passengers on the characterized by AN or restrictive disorder and groups character-
Bus” metaphor is an excellent example of utilizing the power of ized primarily by BN or BED. Splitting groups by diagnostic
the group to act out the scenario. Having the group members play spectrum allowed group leaders to focus on examples that
 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94 91

resonated most with their patient population. For example, when engage in an “urge surfing while having the desire to purge”
discussing urge surfing, the BN group was able to focus on urge to exposure when it was explained as a practice opportunity for
binge while the AN group focused on urges to restrict or over- learning several ACT concepts such as acceptance, willingness, and
exercises. Although binge eating, dietary restriction, and over- defusion rather than just tolerating uncomfortable feelings for no
exercising can occur in a variety of eating disorder diagnoses, we meaningful reason. The connection of values to the behavioral
found that the group was more engaged by targeting experiences exercises also increased motivation and served to provide a strong
all or nearly all patients in a group could relate to. Although the rational for recovery even when recovery proved to be distressing.
separation by diagnosis was not necessarily made explicit to the When patients were asked to describe the most useful compo-
patients, many often expressed that the examples used by group nents of the program they almost always mentioned the in-session
leaders and other patients fit well with their experiences. On experiential exercises, highlighting the benefits of this component
certain occasions when patients accidentally attended the other of the treatment program.
section, they noted that the discussion in their assigned group
seemed more applicable to them. Overall content, including the
focus on eating disorder behaviors as forms of experiential
avoidance, was parallel in the two groups. 8. Common challenges
Initially, we expected that patients with AN might have more
difficulty with ACT concepts as prior studies have indicated that Despite the strengths of the manual, a number of challenges
patients with AN often struggle with types of complex thinking arouse in implementing the treatment. Below, we note several of
requiring cognitive flexibility (Harrison et al., 2009; Lopez, the most common challenges and ways in which we were able to
Tchanturia, Stahl, & Treasure, 2008). However, in our experience, successfully approach them.
we found that patients with AN grasped the concepts as easily as
those in the BN/BED group. Of note, several patients reported 8.1. Managing lack of motivation
feeling more willing to engage in treatment because the therapist
was not attempting to alter long-standing and incredibly ingrained Eating disorders can be incredibly challenging to treat due to
thoughts regarding body weight. This group of patients found that the ego-syntonic nature of the disorder and the corresponding low
the acceptance-based strategies for interacting with internal motivation to change. We noticed that in running our groups, most
experiences were more feasible than cognitive change strategies patients began treatment with ambivalence about recovery. Often
they had previously been taught in other treatment programs. In patients reported a desire to stop certain aspects of the disorder
fact, although only significant at the trend level, initial data from (e.g. binge eating, anxiety, or low self-esteem) but not other
our empirical paper (Juarascio et al., 2013) suggests that AN aspects (e.g. dietary restriction or excessive exercise). When we
spectrum patients may have even stronger benefits from the ACT explored why patients did not want to give up the desired aspects
groups than BN spectrum patients, further reinforcing the use of of the disorder, it was commonly noted that thinness, purging, or
this manual within an AN population. excessive exercising was “working” for the patient by allowing her
to feel more comfortable in her body or reducing other unpleasant
7.4. Conducting experiential activities internal experience such as anxiety or depression. We found that
creative hopelessness strategies were especially well suited in
We experienced certain limitations to the types of activities helping patient realize that the aspects of the disorder that they
that could be included in the groups due to the residential setting. believed were working for them are in reality leading to only
Because patients' calorie consumption is strictly monitored, food short-term benefits. For example, although purging might tem-
exposures could only use very small snacks (i.e., one chocolate or porarily reduce discomfort related to fears of weight gain, it rarely
one pretzel), whereas in a different treatment setting or structure leads to patients feeling better about their bodies in the long-run
larger snacks or meals could be used to practice ACT exercises. and often leads to distress after the purge as patients feel like they
Similarly, exposures to more extreme levels of consumption such have “failed” at treatment. Patients often reported that the thinner
as “planned binges” without vomiting are not possible in this they became and the more frequently they engaged in disordered
context. Although most patients reported that the small food eating behaviors the worse they actually felt about their body. For
exposures were still quite anxiety provoking (and therefore this reason, the manual contains a large number of exercises and
allowed patients to practice ACT skills during the exposure), some metaphors designed to foster a sense of creative hopelessness and
patients had little trouble with the small amounts of food encourage patients to be open to exploring ways of living without
provided. For example, many BN patients noted that they did not the desired symptoms. These exercises were often successful in
experience an urge to binge because they knew that there was no helping patients come to their own conclusions regarding the
access to a larger food supply during group. The fact that patients ineffectiveness of their disordered eating symptoms in controlling
were in a residential treatment facility also limited the extent to distressing internal experiences, and we found that once this
which challenging non-food and body-related exposures could be awareness of ineffectiveness occurred, motivation and openness
assigned since the people, locations, or objects needed to engage to trying the other strategies discussed during group increased.
in these exposures were unavailable. If using the treatment We also found that a strong focus on values work was
manual in a more flexible treatment setting, the types of experi- particularly important among our patients. Given that so many
ential activities, exposures, and homework assigned might be patients had completely given up other areas of life outside the
broadened to allow for more challenging values-consistent eating disorder and lacked clarity regarding non-eating disordered
activities. values, it was challenging for patients beginning treatment to
Despite the limitations we experienced in conducting experi- identify motivators for recovery. Some patients even reported fear
ential activities, patients routinely noted that the activities we of identifying values because doing so created an expectancy that
employed were key components of the treatment. We found that they would work on these areas, and this expectancy invokes the
most patients within our groups were more willing to engage in possibility of failure or other feared outcomes. However, high-
challenging exposures than we originally expected, particularly lighting the degree to which the eating disorder had narrowed
when the rational for the exposures was clearly presented. For their ability to pursue other life goals was often helpful in
example, we found that patients were much more willing to increasing motivation to change disordered eating behaviors.
92 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94

By helping the patient identify what her eating disorder has cost more directly contact their internal experiences and served as a
her and clarifying what she truly wants her life to be about, we useful technique for very preliminary emotion recognition.
found we could increase the patient's willingness to undergo the
challenging work needed to make behavioral changes.
8.4. Managing frustrations with the recovery process
8.2. Differential speed in learning group material
A large number of patients drop out of treatment for eating
As with all group-based treatments, we found that some pathology (Hay, 2013; Watson & Bulik, 2012; Wilson et al., 2007).
patients in the groups grasped the concepts far quicker than other Although this is partially due to a lack of motivation for treatment, a
patients. Because some components of an ACT treatment protocol great deal is also due to the challenging aspect of recovery from the
can be more complicated than other types of psychosocial treat- disorder. Recovering from an eating disorder requires patients to
ments that may be more intuitive, differing rates of learning can engage in a number of distressing experiences such as normalizing
become particularly problematic within this treatment paradigm. their eating, gaining weight, eating “fear foods,” and eliminating
Additionally, patients with chronic starvation may be less able to compensatory behaviors. In addition, much of the challenging work
grasp challenging concepts such as those presented in an ACT of recovery involves working on underlying fear, anxiety, and depres-
treatment approach. As mentioned above, one benefit of the sion that the patient may be avoiding through a hyper-focus on the
rolling nature of the groups was that at any given time, the group body. For all of these reasons, recovery is filled with challenging
contained members who had previously attended several ACT internal experiences; many patients will drop-out of treatment once
groups and members who were just beginning treatment. Having recovery becomes challenging, even if initial motivation was high. We
more experienced group members who could give personal found that ACT is incredibly well suited for managing this barrier to
examples of using ACT strategies often facilitated understanding treatment completion. Because of the strong focus on acceptance of
in newer group members. We also found that simply reminding distressing internal experiences, ACT clinicians can directly address
participants that they would be exposed to the same concepts the emotional challenges of recovery and help patients learn to
repeatedly in upcoming groups and that it often takes several continue maintaining behavioral changes despite discomfort. We
groups to fully understand the concepts alleviated some distress found that warning patients upfront about that process and encoura-
for those who did not entirely grasp the material. The benefits of ging patients to discuss their frustrations and the barriers to recovery
having ACT groups throughout the residential stay became clear as in group was beneficial. A number of patients reported during group
we noticed patients applying the ACT techniques in more complex that they had considered signing themselves out of treatment during
ways as they continued to more strongly grasp the concepts. For particularly challenging times in the recovery process, but by using
example, it was common that patients might report using accep- skills such as urge surfing or reminding themselves of their values
tance-based techniques to help complete meals early in treatment these patients were able to stay in treatment.
and then extending acceptance-based techniques to more com-
plex situations such as managing fears of intimacy later in treat-
ment. For group members who were experiencing more substan-
9. Feedback from patients and staff
tial difficulties with the group material, we would often meet
privately after group for a brief period of time to clarify concepts
Overall, anecdotal feedback from our groups was highly posi-
and provide more individualized support and feedback. Despite
tive, and both staff and patients reported finding the groups to be
initial concerns about difficulty understanding and integrating
a useful addition to treatment. The groups tended to be well
acceptance-based techniques, we found that most participants
attended by patients and homework completion rates were
picked up the material quickly and began applying the techniques
surprisingly high relative to the fact that no other groups at the
outside of groups after attending a relatively small number of
treatment facility required homework completion. Patients were
sessions.
often seen spontaneously gathering together to practice mindful
eating and willingness exercises during meals and snacks. Patients
8.3. Alexithymia who missed groups or who were discharging and would not be
able to attend further groups often requested handout and home-
It is widely accepted that patients with eating disorders tend to work materials from the sessions they have missed or will miss.
be less aware of their emotions than healthy individuals (Merwin Other therapists frequently remarked to our group leaders that
et al., 2011; Merwin & Wilson, 2009; Zucker et al., 2011). Previous their patients had discussed the helpfulness of the groups in
research has demonstrated that individuals with eating disorders individual therapy sessions, and in patients' discharge question-
show deficits in emotion recognition, poor interceptive awareness, naires they often mentioned the ACT group when asked to list the
and poor emotional awareness (Harrison et al., 2009; Harrison, most helpful aspects of treatment. Despite some initial skepticism,
Sullivan, Tchanturia, & Treasure, 2010; Oldershaw, Treasure, therapists at the facility were receptive to the addition of the ACT
Hambrook, Tchanturia, & Schmidt, 2011). In addition, research groups and often sought out our group leaders to learn more about
has indicated that patients with bulimia nervosa and anorexia the ACT groups, including asking for session materials or sitting in
nervosa have high levels of alexithymia, and that it appears to be a on group sessions. This favorable reaction was in stark contrast to
trait that may be unaffected by clinical improvement unless past resistance from the therapists to implementing a more
emotional expression is explicitly addressed in treatment traditional CBT program at the treatment center (Lowe, Bunnell,
(Schmidt & Treasure, 2006). Alexithymia was common in our Neeren, Chernyak, & Greberman, 2011). When the original pilot
participants and often contributed to artificially high fear of study ended and ACT groups were no longer offered, both patients
negative emotions. Combined with tendencies towards high harm and therapists advocated heavily for the groups' return. Because of
avoidance, this led to many patients trying to avoid contact with the popularity of the groups with both staff and patients, the ACT
nearly all emotions. We found that treatment may need to initially groups were made a permanent feature of the treatment program
focus on teaching emotional recognition and identification skills, and non-study staff without extensive ACT training are now
and subsequently on increasing non-judgmental awareness. Mind- utilizing the treatment manual to run on-going ACT groups,
fulness exercises were particularly useful for allowing patients to reportedly with continued success.
 A. Juarascio et al. / Journal of Contextual Behavioral Science 2 (2013) 85–94 93

10. Efficacy Harrison, A., Sullivan, S., Tchanturia, K., & Treasure, J. (2010). Emotional functioning
in eating disorders: Attentional bias, emotion recognition and emotion regula-
tion. Psychological Medicine, 40(11), 1887–1897.
Juarascio et al. (2013) described the first empirical test of this Hay, P. (2013). A systematic review of evidence for psychological treatments in
treatment program, i.e., whether the addition of ACT groups to eating disorders: 2005–2012. International Journal of Eating Disorders, 46(5),
treatment as usual (TAU) at a residential treatment facility for 462–469.
Hayes, S. C., Barnes-Holmes, D., & Wilson, K. G. (2012). Contextual behavioral
eating disorders would improve treatment outcomes. TAU patients science: Creating a science more adequate to the challenge of the human
received an intensive residential treatment, while ACT patients condition. Journal of Contextual Behavioral Science
received these services but additionally attended, depending on Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013).
Acceptance and commitment therapy and contextual behavioral science:
diagnosis, either ACT for AN groups or ACT for BN groups.
Examining the progress of a distinctive model of behavioral and cognitive
Although individuals in both treatment conditions demonstrated therapy. Behavior Therapy, 44(2), 180–198.
substantial decreases in eating pathology, there were trends Hayes, S. C., & Pankey, J. (2002). Experiential avoidance, cognitive fusion, and an
toward larger decreases among those receiving ACT. ACT patients ACT approach to anorexia nervosa. Cognitive and Behavioral Practice, 9(3),
243–247, http://dx.doi.org/10.1016/S1077-7229%2802%2980055-4.
also trended towards lower rates of re-hospitalization during the Hayes, S. C., & Smith, S. (2005). Get out of your mind & into your life: The new
six months following discharge. Overall, results suggest that this Acceptance and Commitment Therapy (1st ed.). Oakland, CA: New Harbinger
treatment program was able to increase efficacy over and above Publications.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment
the specialized residential treatment program. therapy: An experiential approach to behavior change. New York, NY: Guilford
Press.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment
Therapy (2nd ed.). Guilford Press.
11. Future directions
Hayes, S. C., Villatte, M., Levin, M. E., & Hildebrandt, M. (2011). Open, aware, and
active: Contextual approaches as an emerging trend in the behavioral and
Given the growing body of research suggesting that ACT- cognitive therapies. Annual Review of Clinical Psychology, 7, 141–168.
related factors are highly relevant in the development and main- Heffner, M., & Eifert, G. H. (2004). The anorexia workbook: How to accept yourself,
heal your suffering, and reclaim your life. Oakland, CA: New Harbinger
tenance of eating pathology, ACT appears to be well-suited as a Publications.
treatment for this group of disorders. The positive anecdotal Heffner, M., Sperry, J., Eifert, G. H., & Detweiler, M. (2002). Acceptance and
impressions and initial data for our manualized group treatment Commitment Therapy in the treatment of an adolescent female with anorexia
nervosa: A case example. Cognitive and Behavioral Practice, 9(3), 232–236, http:
program further suggest that this treatment is beneficial for adults //dx.doi.org/10.1016/S1077-7229%2802%2980053-0.
with eating pathology. Additional research is needed to evaluate Juarascio, A. S., Forman, E. M., & Herbert, J. D. (2010). Acceptance and commitment
the program in methodologically rigorous trials. We also hope to therapy versus cognitive therapy for the treatment of co-morbid eating
pathology. Behavior Modification, 34(2), 175–190, http://dx.doi.org/10.1177/
further develop the manualized treatment by tailoring the proto- 0145445510363472.
col to different forms of eating pathology. In addition, research is Juarascio, A. S., Shaw, J. S., Forman, E. M., Herbert, J. D., Timko, C. A., Butryn, M. L.,
needed to examine how this treatment approach can be used in et al. (2013). Acceptance and commitment therapy as a novel treatment for
eating disorders: An initial test of efficacy and mediation. Behavior Modification,
other settings such as day programs, intensive outpatient pro-
37(4), 459–489.
grams, or as an addition to outpatient therapy, where patients Kristeller, J. L., Baer, R. A., & Quillian-Wolever, R. (2006). Mindfulness-based
would have more opportunities to work on valued behavioral approaches to eating disorders. In: R. A. Baer (Ed.), Mindfulness-based treatment
change in their daily lives. approaches: Clinician's guide to evidence based and applications (pp. 75–91). San
Diego, CA: Elsevier Academic Press.
Lopez, C., Tchanturia, K., Stahl, D., & Treasure, J. (2008). Central coherence in eating
disorders: A systematic review. Psychological Medicine, 38(10), 1393–1404.
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