ACT-ing to find a new anorexia therapy

Given that there are really no evidence-based treatments for adults with anorexia, researchers, clinicians, patients, and families are all eager to try and find something that will help this group of sufferers. One promising new therapy is Acceptance and Commitment Therapy, or ACT (pronounced like the word “act,” as opposed to saying it like A-C-T). Like DBT (Dialectical Behavioral Therapy), it is derived somewhat from CBT (Cognitive Behavioral Therapy) though it has some important differences.

Two new studies just came out (one in a peer-reviewed journal, the other was presented at the London Conference on Eating Disorders that I was at) that compared ACT to treatment as usual. Neither study really indicated that ACT led to significantly higher decreases in ED thoughts and behaviors compared to normal treatment, although it appeared that ACT did decrease rehospitalization during the 6 months after treatment ended.

What is ACT, anyway?

ACT is unusual in that it’s primary goal actually isn’t the reduction of symptoms of mental illness. Rather the reduction of symptoms is seen as the byproduct of basically living the Serenity Prayer: accepting the things we can’t control and changing the things we can. Mindfulness–observing ourselves and the world around us as they are in the present moment–is a key component of ACT, as is living by our values. For instance, if we value spending time with friends, and a friend invites us out to dinner, then (assuming our schedule is open, etc), we should go. Part of this means accepting that this will make us feel anxious and distressed but committing to the importance of friendship.

Write the authors of the study I mentioned above that was published last week in the Behavior Modification (Juarascio et al., 2013):

Experiential avoidance, or efforts to reduce distressing internal experiences even when doing so is ineffective or impairs the ability to engage in desired behaviors, is thought to be at the root of much psychological suffering (Hayes et al., 2004). Ultimately, prioritizing the avoidance of distressing thoughts, feelings, or urges reduces the ability to take behavioral steps that are needed to live a valued life. Therefore, ACT teaches patients to obtain psychological distance (i.e., defuse) from distressing internal experiences; clarify overarching personal values; create goals that can help patients live a more fulfilling, meaningful life; and increase willingness to experience negative internal experiences in the service of valued behavior.

Given that experiential avoidance is something that many people with anorexia struggle with (you could perhaps argue that this is one of the things at the core of the disorder), it makes something like ACT seem like a good therapy for the disorder.

What the researchers found

I’m going to spend the most time on the study in Behavior Modification, since it’s already been peer-reviewed and it also provides the most information.

In brief, researchers recruited 140 women with eating disorders receiving inpatient treatment at the Renfrew Center in Philadelphia and compared treatment as usual with normal treatment + two weekly ACT groups. Roughly half the women had AN, and half had BN. The average age was 26.75 years, with a range between 18 and 55. Researchers measured changes in BMI, as well as changes in ED thoughts and behaviors, ability to distance oneself from distressing thoughts, psychological acceptance, and emotion regulation.

Women who participated in the ACT arm attended, on average, 3 sessions. Which doesn’t strike me as a particularly strong use of a therapy. THREE sessions? That’s it? This isn’t really receiving a therapy. It’s like watching an infomercial on a Caribbean resort and then saying you’d been there.

Both groups showed large improvements in eating disorder pathology. Not surprisingly, given that the EDE asks about ED behaviors in the previous four weeks. The average stay of the women who completed the study was 28 days, so you would expect a significant decrease in food restriction, binge eating, and purging even if the therapy itself sucked. Still, there wasn’t a larger decrease in the ACT group. Women in the ACT group ate significantly more at a post-treatment food challenge, and they had significantly lower rates of post-treatment rehospitalization (3.5% vs. 18%).

Other variables were “trending towards statistical significance,” which means it’s almost significant, but not quite. This could mean that the study needs to be repeated with more participants to help rule out the vagaries of chance, or that the researchers were trying to create a silver lining in data that didn’t go the way they wanted it to.

The other study, presented at the London Eating Disorder Conference I attended earlier this week, took place in Sweden, led by Ata Ghaderi. In this study, researchers randomized 43 women with anorexia to either 19 sessions of ACT or treatment as usual, which could include everything from weekly psychotherapy to only occasional med checks. Researchers compared BMI, Quality of Life, coping skills, and ED thoughts and behaviors after treatment. Only 58% of the women completed the study.

Both groups showed significant and relatively equal increases in BMI during treatment, and also showed no significant group differences on the Clinical Impairment Assessment.

In conclusion, then, it doesn’t appear that ACT was very successful at treating EDs, at least in these early preliminary studies. More research will have to be done to determine if there is a particular subset of patients that it does help, or whether it is useful as an adjunct to other treatments, such as CBT, DBT, or FBT.

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7 Responses to “ACT-ing to find a new anorexia therapy”

  1. For me, one of the biggest obstacles to success in treatment is this: I have a very loud, constant ed voice in my head. It is rigid, structured, and clear. It is with me daily, even hourly. The voices of my treatment team, on the other hand, are only with me one or two hours per week.

    They’re just not loud enough, not strong enough, not impactful enough.

    And I do not have my own voice of recovery. Just the ed voices.

    A way my treatment team and I have begun to compensate: I was diagnosed with Asperger’s last summer. We researched how to communicate with my Aspie brain, which craves repetition, organization, rhythm. We developed a written contract with simply worded, bullet-pointed expectations. My therapist and I go over it now at the beginning and the end of every single session. At the beginning, she goes over each point and asks me to report on my compliance. At the end, she reads each point out loud, then hands the contract to me, and I read each point back and commit to it. Over and over and over. And things are finally sinking in.

    Within just a few weeks, we began noticing BIG changes in my ability to comply with treatment. The bullet-pointed “voice” of our contract began to establish a place in my head, which could counter the ed voices on a daily basis.

    Before, it felt like a sea of confusing words and instructions that would swim around in my head until they spun down a mental drain while the rigid, comfortable ed voice repeatedly stepped back in and back on top. It was 2 days of “recovery,” 5 days of ed, 3 days recovery, 4 days ed, etc. Now, it has been almost 5 months of keeping to my meal plan exactly, with only 2 days in there where I slipped and made ed choices. That’s pretty damn impressive. I finally feel like I am succeeding.

    I’m not always happy about it, and there are days when I throw the contract on the floor after I read it. There are days when I cry as I read it. There are days when I don’t want to read it. But we always do anyway, and that is what is keeping me strong, and establishing a “recovery voice” inside my head.

    I know not everyone with anorexia has Asperger’s, but many people at least have some of the traits. The perfectionism, the need for concrete black-and-white instructions, the craving for structure, repetition, rhythm. The ed provides a rigid, comforting structure. For me, having my treatment team “imitate” that rigid structure, but in recovery terms, has been a means for success.

  2. I’ve tried ACT therapy (hoping to start again sometime) and I found it very helpful. Other types of therapy haven’t worked for me, but the techniques I learnt are useful – particularly ‘noticing’ the thoughts and not doing anything about them 🙂

  3. Hi just wanted to give you a brief heads up and let you know a few of the pictures aren’t loading properly. I’m not sure why but I think its a linking issue.
    I’ve tried it in two different browsers and both show the same results.

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