Hi Carla,

Although I have very limited exposure with eating disordered clients, I do have
fairly extensive experience with children. Many of whom have demonstrated
severe behaviors. The fact is, when working with children they rarely
prioritize in quite the same way I or their parents might. It is the prime
landscape for power struggle, which I suspect occurs in your setting as
described as well.

It is my experience that the core value children work towards is acceptance.
The way they approach it can be problematic but underlying their behavior is a
need to feel they belong. I would think that would also be true of an
eating-disordered client as well.

The struggle originates when a person such as yourself or other authority
figures feels (and rightfully so) that the behavior is life threatening and
rejects it outright. What I have found with children who behave severely is
that if they cannot have acceptance, they will settle for control. The harder a
person who they feel is critical of them struggles to make things right, the
more they are reinforced to exert control.

From my experience, I find that the most effective intervention I have been able
to implement is to teach parents to empower the child rather than struggle with
them. To shift the focus from what they (the children) are doing wrong, to what
is possible in other areas that would facilitate acceptance.

This can be very effective in quite short order but of course I have the
advantage of working with the parent. And quite often, this parent has been the
one most critical of the child in the past. When they begin providing the child
with a lot of encouragement and positive feed back, change is sure to follow. I
am sure you do not always have this luxury.

I hope this has been helpful.

George



--- In eatingconcernsandcontextualpsychology@yahoogroups.com, "carlajoywalton"
<carlajoywalton@...> wrote:
>
> 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.
>