Treating BED

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Using Mindfulness & Acceptance and Commitment

Therapy (ACT) for Treating BED

Joyce D. Nash, Ph.D.drjnash@comcast.netwww.drjoycenash.com

@drjnash

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My Book & Blog

• “Lose Weight, Live Healthy: A Complete Guide to Designing Your Own Weight Loss Program”

www.loseweightlivehealthyguide.com

www.loseweightlivehealthyguide.com/blog/

For a copy of this powerpoint presentation, go to:

www.loseweightlivehealthyguide.com/Renfrew_2011_ACT_BED_Nash

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Agenda

• How ACT differs from Cognitive Therapy

• Mindfulness• BED essentials• Introduction of an

actual BED client• Basics of ACT• Videos • Obesity-related

research

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ACT is like a New Concept Car

• ACT has both theoretical and empirical support• Based on Rational Frame Theory (RFT)• Developed by Steven Hayes, Ph.D., at

University of Nevada at Reno, and his associates

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How ACT Differs from Other CBT Approaches

• Does not strive to change negatively perceived thoughts and feelings, but rather emphasizes acceptance of these private events

• Does not dispute evidence for thoughts

• Is context-focused (not content-focused)

• Is not symptom-focused

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What ACT Does In Session

• Uses experiential exercises in session

• Makes extensive use of metaphor and paradox

• Targets experiential avoidance and cognitive fusion

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Acceptance and Commitment Therapy (ACT)

• A – Accept your thoughts, feelings, memories, and other private events as they occur moment to moment, without judgment

• C – Clarify and connect with personally-defined values that give direction to your life, and set goals that support these values

• T – Take effective action in accordance with your goals and values

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Aim of ACT

To help us create a rich, full, and meaningful life, while accepting the pain that life inevitably brings

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Sources of Pain and Discomfort

• Clean Discomfort

• Dirty Discomfort

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ACT and Mindfulness

• ACT is not just mindfulness

• ACT uses mindfulness as a means of accessing the observing self in the present moment

• The observing self has no words but the thinking self is chattering continuously

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What is Mindfulness?

• A mental state of awareness, focus, curiosity, openness, and receptiveness that allows you to engage fully in your here-and-now experience without judgment or referring to the past or future

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Essentials of BED Diagnostic Criteria

• Recurrent episodes

• Larger than normal quantities of food

• Feeling out of control

• No regular use of compensatory behaviors

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Agenda of Control

• Lack of control implies the need for more control• Control usually works in the external world• Doesn’t work well for thoughts and emotions• Binge is an attempt to stop thinking and feeling, that is, it

is an experiential avoidance strategy

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Introducing Tina

• Presenting complaints• History• Eating triggers

– Family dynamics– Emotions – Unstructured time– Feeling of not fitting in– Social situations– Hunger, fatigue

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Triggers for Binges and Overeating

• Negative emotions (emotional eating)• Positive social experiences• Low distress tolerance• Restrictive eating/dieting• Unstructured time/transition times• Readily available, high-energy, palatable food

(food cues in the environment)• Evolutionary motivational system to ensure

survival

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Mindful Questions To Ask

• What is triggering me to eat this food right now? (i.e., thoughts, feelings, cues)

• What are my options other than eating? (i.e., what do I really need to do now?)

• Is eating this food in line with my values and the option I want to choose at this time?

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Core Messages of ACT

• Accept that you have at best limited control over your internal experiences, i.e., thoughts, emotions, memories, and internal experiences

• Commit to taking actions that enrich your life because they are based on your values

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ACT and Values

• Values are statements about– What you want to be doing with your life– What you want to stand for– How you want to behave on an ongoing basis

• Values clarify what gives your life a sense of meaning or purpose

• Values are chosen life directions

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Processes that Keep Us Stuck

• Cognitive Fusion– You become fused with, melded with, and inseparable

from your thoughts– Thoughts dominate behavior– Leads to unworkability

• Experiential Avoidance– Trying to avoid, get rid of, suppress, or escape from

unwanted thoughts, feelings, memories, fears

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Processes That Work

• Defusion– Wherein thoughts, feelings, and urges come to be

experienced from a psychological distance, i.e., the observing self

– Being able to have a thought, feeling, craving, or urge without trying to suppress, believe or act on it

• Acceptance– Learning to tolerate or be willing to have aversive

internal experiences in the service of goal-related behavior

– Alternative to control strategies

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Choosing Based on Values

• Some ideas are worth considering• Ask yourself, “Does this contemplated action

move me toward something I value?”• A good thing overdone undermines the value of

health and well-being

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Definition of Psychological Flexibility

• An individual’s ability to connect with the present moment fully, as a conscious human being, and to change or persist in behavior that is in line with identified values

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ACT in a Nutshell

Present focused

Experiential/metaphor

Between session work

Applicable to a variety of problems

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Some Obesity-related Research• Lillis, J., Hayes, S. C., Bunting, K., & Masauda, A. (2009).

Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37:58-69.

• Tapper, K., Chaw, C., Ilsley, J., Hill, A. J., Bond, F. W., Moore, L. (2009). Exploratory randomized controlled trial of a mindfulness-based weight loss intervention for women. Appetite, 52:396-404.

• Forman, E. M., Hoffman, K. L., McGrath, K. B., Herbert, J. D., Brandsman, L. L., Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: an analog study. Behavior Research and Therapy, 45:2372-2386.

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More Obesity-Related Research • Lillis, J., Hayes, S. C., & Levin, M. E. (2011). Binge eating and weight

control: the role of experiential avoidance. Behavior Modification, 35:252-264.

• Forman, E. M., Butryn, M. L., Hoffman, K. L., & Herbert, J. D. (2009). An open trial of an acceptance-based behavioral intervention for weight loss. Cognitive and Behavioral Practice, 16:223-235.

• Lillis, J., Levin, M. E., & Hayes, S. C. (2011). Exploring the relationship between body mass index and health-related quality of life: A pilot study of the impact of weight self-stigma and experiential avoidance. Journal of Health Psychology, 16(5):722-727.

• Weineland, S., Arvidsson, D., Kakoulidis, T, & Dahl, J. (2011). Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Obesity Research and Clinical Practice, e-l to e-10. Published online 18 May 2011.

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Lillis, J., et al. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37:58-69.

• N = 84

• Groups– Intervention

• 1-day, 6-hour, mindfulness and acceptance-based workshop targeting obesity-related stigma and psychological distress (N = 43) (BMI = 33.59)

– Wait list control• (N = 44) (BMI = 32.5)

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Lillis et al

• Participant requirements– Had completed at least 6 months of a

structured weight loss program in last 2 years– Were recruited from local weight loss clinic

and fro community with flyers

• Assessment at baseline and 3 months later– 8 self-report and 3 objective measurements

(e.g., breath-holding, BMI changes, weight)

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Lillis et al

• Targets for change– Weight-related stigmatizing thoughts and

distress– Clarification of life values– Identification of barriers to values behavior– Fostering of behavioral commitments related

to life values

• Intervention materials: ACT Workbook

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Lillis et al

• Results– No pretreatment differences between groups– Less psychological distress– Better quality of life– Lower levels of weight-related stigma– Greater weight loss in ACT condition

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Lillis et al

• Conclusions– Without any focus on weight control per se,

the ACT intervention had impact on stigma– At the 3-month mark, the ACT group had

improved significantly more on all outcome measures than the waiting list control

– Changes in stigma, distress, and quality of life could not be attributed to changes in weight, suggesting that the ACT intervention had an independent effect

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Tapper, K., et al (2009). Exploratory randomized controlled trial of a mindfulness-based weight loss intervention for women. Appetite, 52:396-404.

• N = 62

• Beginning BMI (22.5 to 52.1)

• Participant requirements and recruitment– BMI of over 20– Over 18 years of age– Actively attempting to lose weight– Recruited via advertisements and articles in

local papers, in community, and via website

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Tapper et al

• Measurements– Questionnaires, BMI, physical activity, mental

health, qualitative data– Baseline, 4 months, 6 months

• Groups– Intervention group: invited to attend 4, 2-hour

workshops (N = 31)– Control group: asked to continue with their

normal diet

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Tapper et al

• Intervention components– Values– Cognitive defusion– Control agenda– Acceptance/willingness (instead of avoidance)– Mindfulness/self-awareness– Committed action– Review

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Tapper et al

• Results– At 6 months ACT group showed significantly

greater increases in physical activity– At 6 months there were no differences in

weight loss or mental health until 7 people who said they never used the principles were excluded; then results showed significantly greater reduction in BMI.

– Reductions in BMI were mediated primarily by reductions in binge eating

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Tapper et al

• Conclusion– Qualitative data suggested that the most

successful part was the cognitive defusion component, especially when used with regard to exercise

– Participants reported some difficulty in understanding the acceptance/willingness component of ACT

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Forman, et al. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: an analog study. Behavior Research and Therapy, 45:2372-2386.

• N = 98 (Mean BMI = 25)• Participants: undergraduate students• Hypotheses:

– Craving ratings will predict consumption of chocolate– Scores on the Power of Food Scale (PFS), which

measures individual susceptibility to the influence of food being present), will predict cravings and chocolate consumption

– Intervention (acceptance-based strategies vs. control-based strategies vs. no intervention) will differentially impact craving and chocolate consumption

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Forman et al

• Intervention– Subjects were given transparent boxes of

specially marked chocolate Hershey’s Kisses and instructed to keep the chocolates with them, but not to eat them, for 48 hours

– Then subjects were randomized into one of three groups

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Forman et al

• Groups– No intervention, i.e., told not to eat chocolates– Instruction in control-based coping strategies,

i.e., distraction and cognitive restructuring, based on LEARN manual

– Instruction in acceptance-based coping strategies, i.e., self-awareness, cognitive defusion, and acceptance of urges and cravings without acting on them

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Forman et al

• Measures– Power of Food Scale (a self-report measure of

psychological sensitivity to the food environment)

– Food Craving Questionnaire (a self-report rating of chocolate cravings)

– Other researcher devised Likert scales – Surreptitiously-recorded chocolate

consumption (i.e., collection of boxes of chocolates and counting of missing kisses)

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Forman et al

• Results– There was a high overall abstinence rate of 91%– Subjects who experienced higher craving frequency,

intensity, difficulty, and distress were more likely to eat some of the chocolates

– Higher scores on the PFS predicted greater cravings and food consumption

– Effect of the intervention depended on how susceptible subjects were to temptation, with ACT strategies associated with better outcomes among those with highest susceptibility

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Recommendations for Further Study

• Russ Harris. (2006). “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy”. www.actmindfully.com.au/upimages/Dr_Russ_

Harris-a_non-technical_overview_of_act.pdf • Russ Harris. (2009). ACT Made Simple.• J. B. Luoma, S. C. Hayes, R. D. Walser. (2007).

Learning ACT. • Steven Hayes, Kirk Strosahl, Kelly Wilson. (1999).

Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change.

• Steven Hayes, (2007). ACT in Action, DVD Series.