Hi all,
I'd like input from people working across different clinical groups
that may help shed some light on the issue of how ACT can be applied
for persons with Eating Disorders when the client doesn't prioritise
changing the Eating Disorder behaviours. Don't worry if you don't
know about Eating Disorders, all I'm looking for is some open-minded
thinking on this. Some colleagues and I have been talking about
using ACT when folks with Anorexia are at a low weight and are not
willing to put on weight. Amongst us, we've had some differences of
opinion as to `what the ACT stance would be'. With most
psychological issues, generally people come willingly to treatment
and wanting to get rid of their symptoms. With Anorexia, ambivalence
is part of the disorder, and generally, people don't want to put on
weight.

My question is really how much do we target behaviours associated
with the disorder, even if that's against what the patient's agenda
is? Let me contrast it with social phobia, for example. With social
phobia, the associated behaviours are generally about avoiding
social situations or situations where the person is exposed to
perceived scrutiny. Mostly people with social phobia come because
the avoidance is
getting in the way of their values and it's clear how the avoidance
behaviour stands in the way of recovery. Hence, they usually readily
accept that avoidance is a target of treatment (in either CBT or
ACT). With Anorexia and Bulimia, often patients do not see the
Eating Disorder behaviours as interfering with valued living. So
then it becomes our agenda and not theirs.

We can work on increasing psychological flexibility in a values
consistent way. However, often the patient will claim that this can
be done whilst they stay underweight. For example, you might see a
patient who values learning and wants to go to school, and a side
agenda is about eating unsupervised at school so they can keep the
anorexia. Or a patient values being a good and connected friend but
maybe doesn't have the cognitive capacity to stay present and
connected due to malnutrition. It can feel fraudulent working with
clients on an agenda that is handicapped unless they gain weight.

I have just finished co-facilitating an ACT group for Bulimia that
focussed on general ACT principles and did not specifically target
reduction of Bulimic behaviour. I saw one of the participants last
week for her post-assessment. She is delighted with the gains she
has made through the group and has made amazing progress on every
point on the hexaflex…. And still bingeing and purging everyday.
This doesn't feel okay to me. I can work on my side of the hexaflex
and accepting my disappointment etc, but is this really good enough?
My co-facilitator and I weighed up at the beginning how much we
needed to address bulimic specific behaviours, but decided not to
because it was our agenda and not theirs.

Then there is the more extreme, yet common situation of patients
with Anorexia who aren't willing to work on weight gain and are at a
dangerously low weight. Do you make talking about the weight,
getting agreement about need for weight gain a priority? And yet,
when we do that, we're really prioritising what we see as important,
not what they want for their life. I heard Kelly Wilson use a great
metaphor in Chicago about how if we're saying something is a goal to
work on and it's not what the client wants to work on, it's really
like a builder coming in and building a new bathroom on the house
because that's what the builder thinks is needed, when what the
client asked for was a new kitchen and they don't think they need a
new bathroom. However, if we don't address weight gain, this is at
the risk of the patient doing permanent damage to their bodies or in
some cases, dying.

Sorry for the length of this. In case you've forgotten what my
original question was, it's really `what would be an ACT consistent
stance in working with a patient who doesn't see their behaviours as
a problem and yet, these behaviours are psychologically inflexible
and interfere with valued living?'

If you work with people with Eating Disorders, how do you approach
these issues? I thought people that work in substance abuse areas
might also have some ideas in this regard. If anyone has any ideas,
please suggest them (even if you're mind says they're obvious or
unhelpful).

Thanks,
Carla.

P.S. I am sending this to both the general ACT listserve as well as
the ACT & Eating Concerns listserve. So, apologies if you're getting
it twice.