ACT‐Based 

Family Intervention for 
Ad l
Adolescents with Anorexia Nervosa
t ith A i N
Rhonda M. Merwin, PhD 
Rhonda M Merwin PhD
C. Alix Timko, PhD 
Nancy L. Zucker, PhD
y ,
Lindsay Martin, BS & Ashley A. Moskovich, BA
• Special
Special thanks to Lisa Honeycutt, MA, James 
thanks to Lisa Honeycutt MA James
Herbert, PhD, Rebekah Teetsel

…and to all the families that are teaching us 
h
how to do this work 
d hi k
 An invitation…
An invitation…
• To step into this space,
To step into this space
• in the service of something. 
• Mud in a glass 
di l
• and mountain climbing…
 Dying to be thin? (we think it
Dying to be thin? (we think it’ss 
about something else)
• Anorexia nervosa (AN) is a devastating condition 
in which behavior is so profoundly narrow, rigid 
and disconnected from experience that 
d di t df i th t
individuals are not able to meet basic needs
– Highest mortality rate of any psychiatric illness
Highest mortality rate of any psychiatric illness
– 4‐20% of individuals with AN will die 
prematurely as a result of self imposed
prematurely as a result of self‐imposed 
starvation or suicide
STATE OF THE UNION
 Empirically Supported Treatments 
(ESTs) for Anorexia Nervosa
•
•
•
•
•
•
•
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy‐Enhanced
Enhanced 
(CBT‐E)
 CBT and CBT‐EE for AN
CBT and CBT for AN
• Ego‐syntonic
g y nature of disorder
– Attempts at direct change of thoughts are often met 
with resistance
– Often less credible/acceptable
Often less credible/acceptable
• Behavior is rewarding in short‐term 
• Relies on very verbal ways of knowing (not 
Relies on very verbal ways of knowing (not
experiential)
• Use of distraction and other strategies may 
reinforce avoidance
i f id
• In adolescents  ‐> no real trials for CBT
 And how’ss it going
And how it going

Source: Steinhausen, H‐C. (2002). The Outcome of Anorexia Nervosa in the 20th Century .  American Journal of 
Psychiatry, 159,  1284‐1293. 
 Family‐Based
Family Based Treatment
Treatment
• Phase
Phase I: Refeeding
I: Refeeding the patient
the patient
• Phase II:  Negotiations for a new pattern of 
relationships
• Phase III:  Adolescent issues and termination
– e.g., Maudsley Approach
 Family‐Based
Family Based Treatment
Treatment
• Effective for many families
Effective for many families
– Exception is those high in expressed emotion
• Best
Best for adolescents with a short duration of 
for adolescents with a short duration of
the disorder; LT outcomes unknown
• Lack of focus on underlying etiological or 
maintenance factors
Cumulative Prevalance Rates
Cumulative Prevalance Rates
 Adolescence:  Essential Time to 
Intervene
• Decrease in gray matter in prefrontal regions 
of the brain
• Changes in dopaminergic activity
• Increase in myelination in pre‐frontal cortex
• Increase in connections across cortical and 
sub‐cortical areas

better coordination of emotions and 
cognitions over the period of adolescence 
Steinberg, 2009 
Best time to intervene, ,
but are we intervening 
g
in the best way?
• Pause
 What it’ss like to be in the room
What it like to be in the room
• Sampling the therapist
Sampling the therapist’ss experience
experience
controlling

resistant
dying
starving difficult
diffi lt
thin
• Reactions
 Slip inside the skin…
Slip inside the skin…
• Sample
Sample the experience of a parent of a child 
the experience of a parent of a child
with anorexia nervosa
• PAUSE, BREATHE
PAUSE BREATHE
 Slip inside the skin…
Slip inside the skin…
• Sample
Sample the experience of the adolescent with 
the experience of the adolescent with
anorexia nervosa
Something is really 
Something is really
wrong with you
wrong with you.
 How do you protect yourself?
How do you protect yourself?
• Being
Being stripped of your armor
stripped of your armor
• Get what it would be like to have something taken 
away from you… the only thing that has provided you 
y y y g p y
with a sense of pride, comfort, safety, reprieve.
The functional nature of the ED
The functional nature of the ED
• So EDs are coping strategies, they
So EDs are coping strategies, they’re
re functional
functional
• Cope with what? The narratives
• Anorexia, my friend . . . . you are the source of my security, 
my guard. . . 
• I really need you to provide direction in everything I do.
• You let me hide from things I know that I can’t deal with…
f g
• Anorexia, you make me feel special…
• ‐> AN provides sense of safety, predictability, 
mastery and control, eliminates ambiguity, etc ‐> 
d l li i bi i
attenuates negative and promotes positive 
feelings. 
feelings
 Racing against the clock
Racing against the clock
• Why
Why you can
you can’tt just treat the adolescent; 
just treat the adolescent;
Inclusion of parents in treatment
• Deal w/ safety issue in session with parents, 
Deal w/ safety issue in session with parents
allows the therapist to be more present with 
the adolescent
the adolescent
 Short term health                                  Long term health 
consequences consequences

• Weight loss • Osteoporosis/osteopenia
• Amenorrhea • Fertility issues
Fertility issues
• Thinning hair
• Cognitive impairment
• Lanugo
• Carotinemia • Death
• ANS down‐regulation
• Acrocyanosis
• Ed
Edema
• Hyperactivity
• Hypokalemia
• BREAK
 Summary
• Effective
Effective treatments sparse without long
treatments sparse without long‐term
term 
outcomes
• Know it
Know it’ss important to include parents, but 
important to include parents but
unclear how
• Need to address features with prognostic 
N d dd f ih i
significance and functional nature of 
symptoms
 ACT
• Emphasis is on the function of behavior and
workability, including but not limited to, the ED. 
• Goal is to increase psychological flexibility, i.e., 
ability to contact the present moment, fully and 
without defense, and cease or persist in 
b h i
behaviors that would be effective given one’s 
h ld b ff i i ’
values and what the environment affords. 
ACT in a
question…
q Contact with the a
at thiss time,
e, in thiss
Present Moment
are you willing to situation?
have that stuff,
fully and without of your chosen
defense values
Acceptance Values

if the answer is
“yes” that’s Psychological
Flexibility
AND ddo what
h
takes you in the
direction
Defusion Committed
as it is, and not as Action
what it says it is,

Given a distinction between you &

Self as
Context the stuff you are struggling with
and trying to change
 Contact with the
Present Moment
Open Centered Engaged

Acceptance Values

psychological
flexibility

Defusion Committed
Action

Self as
Context
 Contact with the
Acceptance and
Present Moment
Mi df l
Mindfulness
Processes

Acceptance Values

Defusion Committed
Action

Self as
Context
 Contact with the
Present Moment Commitment
and Behavior
Change Processes

A
Acceptance
t Vl
Values

Defusion Committed
Action

Self as
Context
Acceptance‐based Separated Family 
Th
Therapy (ASFT)
(ASFT)
– Separated Family treatment
Separated Family treatment
• High EE, caregiver burden, assoc features
• Adolescent and parent have different needs
– Adolescent  ACT presented in individual format
– Parent  Off the C.U.F.F. parent skills program 
ff p p g
(Zucker, 2006) enhanced by ACT
– 20 sessions over 6 mths
• 16 separated
• 4 conjoint (biweekly)
ASFT Overview
ASFT Overview
 MODULE 1: Setting the Stage
MODULE 1: Setting the Stage
• Therapeutic relationship in ACT
• Values as compass in the most general sense
• Adolescent: 
– Th
Thoughts/feelings about treatment HW 
ht /f li b tt t t HW
(begin to facilitate observation/openness)
– Creative representation of self HW 
(foundation for values, self‐as‐context)
• Parents: 
– Activating
Activating the family, observing values/barriers/urges, and 
the family observing values/barriers/urges and
strengthening the parent team  
– Teaching ED as coping, the dance of parenting, CUFF style, 
targets and principles of behavior change
targets and principles of behavior change
 MODULE 2
ED as Avoidance: Tools for Functional
ED as Avoidance: Tools for Functional 
Assessment
• Adolescent Timeline
Adolescent Timeline
Positive Negative
Reinforcers Reinforcers
Internal Provided a sense of Reduced painful or
control, safety, uncomfortable affective
predictability, or experiences, such as guilt or
dependability; Organized shame; Reduced ambiguity,
ambiguity
the world; Increased chaos, feelings of
sense of mastery or pride ineffectiveness or low self-
(felt special, moral, or worth
dominant)
External Was the source of Took away uncomfortable
compliments, attention, sexual attention, weight-
envy or adoration of related teasing, isolation, or
others. Lead to increased responsibility
care-taking from others
Assessment is informed by Parents
Assessment is informed by Parents
• A
A key parent tool for 
key parent tool for
understanding and 
intervening upon
intervening upon 
their child’s ED: The 
Eating Disorder
Eating Disorder 
Wave
 Broadening our view
Broadening our view 
• Expand
Expand to functional classes
to functional classes of avoided events 
of avoided events
and avoidant repertoire.
– Food/eating takes on the psychological function of 
Food/eating takes on the psychological function of
other painful content and is thus aversive
– What would you rather think about… 
What would you rather think about
• 801, cards exercise/role play, case example 
(AL)
 Long‐Term
Long Term Costs
Costs
• Explore
Explore the limits of system, how it has gotten 
the limits of system how it has gotten
in the way (if it has).
Stuck
Stuck
 Difficult thoughts, feelings, Behaviors aimed at decreasing 
bodily sensations contact with these private events
(e.g., the thought  “I am fat and no (e.g., following dietary rules, 
one will like me,” feelings of worthlessness,
ll l k ”f l f hl avoiding social situations
avoiding social situations, 
stomach tightness, anxiety) Achieve, achieve, achieve, …)
The System
th t ttraps
that
Short term relief
Short‐term relief
(e.g., Feel successful, a moment 
of respite)
Long‐term costs
 Refining the Contract
Refining the Contract
• Build
Build a therapeutic contract around 
a therapeutic contract around
something that is personally meaningful to 
him/her
 MODULE 3
Open, Centered, Engaged
d d
ADOLESCENTS
• Teach observation and acceptance of 
experience (as it unfolds in the present
experience (as it unfolds in the present 
moment), identifying valued‐directions and 
active choosing.
active choosing. 
• Build a sense of self that is independent of 
content.
content
What we
aimingg for,, Contact with the a
at thiss time,
e, in thiss
Present Moment
in each are you willing to situation?
moment… have that stuff,
fully and without of your chosen
defense values
Acceptance Values

if the answer is
“yes” that’s Psychological
Flexibility
AND ddo what
h
takes you in the
direction
Defusion Committed
as it is, and not as Action
what it says it is,

Given a distinction between you &

Self as
Context the stuff you are struggling with
and trying to change
 Contact with the
Present Moment
Open Centered Engaged

Acceptance Values

psychological
flexibility

Defusion Committed
Action

Self as
Context
“ See….That
See That’ss the stuff I was talking about
about.”
 Bad News Radio!
Bad News Radio!
Giving you nothing but the best,
best all
day long, NON-STOP ROCK!
 Which Path Will You Choose
in This Moment?

Old, familiar, leads to here.  New, feared, but vital, meaningful.
• Pause
 PARENT SKILLS
(OFF THE CUFF ACT IFIED)
(OFF THE CUFF ACT‐IFIED) 
 Core Skills: Surfing
Core Skills: Surfing
Emotiional Intensityy Increases

Ration
nal Cognition Decreases

Staying focused on the value‐guided direction
Values and Self‐Awareness
Values and Self Awareness
Perfectionism and Values
Perfectionism and Values

Values
 Reinforcement 
Reinforcement

Extinction of  Differential 
Eating  Reinforcement 
Disorder  of Other 
Symptoms Behaviors
 Open, Centered, Engaged
PARENTS
• Purpose
– To address ED behaviors
– To be role models
To be role models
– To directly shape healthy (approach‐based) coping 
in their child
in their child
 Addressing barriers to implementing 
parent skills
parent skills
CHOOSE

ghts, feelings, bodily states,

• ACT wrap around
d

on, ambigguity…
ehaviorall
s, confusio
mpeting be
MOVE

EXPOSURE
memories, com
Negatiive thoug

predispositions
DEFUSION
ACCEPTANCE
MINDFULNESS
 MODULE 4: Behaving Flexibly
MODULE 4: Behaving Flexibly
• Building
Building broader and broader repertoires of effective 
broader and broader repertoires of effective
action 
– adolescent takes increasing responsibility
g p y
– in‐session symbolic approach activity (S10)
– add healthy coping to parent sheet
add healthy coping to parent sheet
 MODULE 3: Conjoint Sessions
MODULE 3: Conjoint Sessions
• Structure and content
Structure and content
• Other issues
– Blind versus nonblind
Bli d bli d weight
i ht
– Function of parents’ “need to know” 
– Session order – parent vs. adolescent
• Experiential
Experiential exercise (or role play) with 
exercise (or role play) with
discussion of components of the hexaflex, 
targets and strategies
targets and strategies
 ACT Model of Problems in Living
Contact with the Present Moment
Dominance of the conceptualized
feared future & regretted past

Values
Lack of values clarity;
Acceptance Dominance of pliance and
Experiential
avoidant tracking; values
avoidance
avoidance; values as burden

this
psychological
psychological
inflexibility
space

Defusion Inaction, impulsivity, or

Cognitive
fusion avoidant persistence
Committed
Action

Attachment to conceptualized
self; Impoverished sense of self
Self as Context
 The ACT Therapeutic Model
Contact with the On-going, nonjudgmental
Present Moment contact with psychological &
environmental events as
they occur

Acceptance Values
Active embrace of Chosen qualities
thoughts,
g , feelings,
g , of p
purposeful
p
bodily sensations psychological action, instantiated
`
flexibility moment by moment

Defusion Committed
Decreasing the literal Action
quality of thought; Recognizing Building patterns
the process, not just the product of effective action
linked to chosen values
Self as
Locus or perspective Context
from which private events
are experienced
 Hexaflex and AN: Some Unique Issues
and AN: Some Unique Issues
• Values
• Self‐as‐context
• S i i h
Staying in the present moment
• **More at Panel Discussion tomorrow
 Conditioned aversives in the
therapy
h room
• Observing behavior in session
– Patient
– Therapist
• Imagine your most difficult patient
 ASFT
• Phase I: Development of treatment manuals/materials
p

• Phase II: Recruitment of 6 families to pilot and refine 
p
intervention

• Phase III: Recruitment of an additional 16 families to 
test effectiveness (incl feasibility, acceptability, effect 
size estimates to power larger trial)
 ASFT Enrollment
ASFT Enrollment
– Inclusion criteria
• Aged 11‐18
• Meets criteria for AN
• Appropriate for outpatient care
Appropriate for outpatient care 
• At least average intellectual functioning
• Living at home 
– Exclusion criteria
• Actively suicidal
• Psychosis, current substance abuse
Psychosis current substance abuse
• Learning disability or PDD
 Description of First 4 Participants
Description of First 4 Participants
◊ Age range 12
Age range 12‐16
16
◊ Variety of family structures 
◊ Treatment familiar and naive
EDE Subscales – Adolescent (Parent Report)
EDE Subscales – Adolescent (Parent Report)
Restraint Eating  Weight  Shape  Global
Concerns Concerns Concerns
801 2 20 (3 60)
2.20 (3.60) 0 20 (1.20)
0.20 (1 20) 0 00 (1 25)
0.00 (1.25) 0 38 (1 50)
0.38 (1.50) 0 69 (1.89)
0.69 (1 89)
804 3.80 (3.80) 1.20 (1.40) 3.60 (3.50) 2.63 (3.25) 2.81 (2.99)
807 4.00 (3.60) 1.20 (0.00) 3.20 (1.50) 3.88 (2.63) 3.07 (1.93)
810 5.80 (4.60) 1.50 (2.40) 1.50 (1.25) 4.63 (3.25) 3.36 (2.88)
 801 
50
45
40
35
MI Percenttile

30
25
20
BM

15
10
5
0
1 2 3 4 5 6 7 8 9 10
Session Number
 804
35

30

25
MI Percenttile

20

15
BM

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Session Number
 807
70
60
50
BMI Percentile
e

40
30
20
10
0
1 2 3 4 5 6
Session Number
 810
45
40
35
BMI Percentiile

30
25
20
15
10
5
0
1 2 3 4 5 6
Session Number
 STAY TUNED
STAY TUNED. 
Contact us.
Contact us.
Rhonda.merwin@duke.edu
CTimko@Towson.edu
Nancy zucker@duke edu
Nancy.zucker@duke.edu
 A review
A review…
• What features of AN are particularly well‐matched to 
acceptance‐based strategies?
p g
– Acceptance‐based strategies address avoidance and control of emotions 
and other motivational states common among indv with AN. These 
strategies might also be well‐matched to this patient population given 
the ego‐syntonic
the ego syntonic nature of the symptoms and the emphasis on 
nature of the symptoms and the emphasis on
experiential (rather than verbal ways of knowing).
• What are the core components of the protocol designed to 
treat adolescents with AN?
– ACT based individual therapy for the adolescent. 
– Parent skills training within an ACT framework.
– Setting the stage for treatment, functional assessment, 
open/centered/engaged, behaving flexibly, conjoint sessions. 
/ t d/ d b h i fl ibl j i t i
• What is one strategy or exercise adapted for use with this 
population?
– Timeline used for functional assessment.
Ti li d f f ti l t
– Wave as metaphor for observing internal experience.