Response: Principles of ACT Applied to Anorexia
Response Paper cause bad behavior. We expend e n o r m o u s effort in our
Core Principles in Acceptance
and Commitment Therapy:
An Application to Anorexia
Kelly G. W i l s o n a n d M i g u e l R o b e r t s
University o f Mississippi
Acceptance and Commitment Therapy (ACT) views cog-
nition and emotion differently in their roles in psychologi-
cal problems. Both popular culture and many models of
psychopathology conceive of negative thoughts and emo-
tions as states that must be eliminated, reduced, or sup-
planted. ACT posits that these negative emotional, cogni-
tive, and bodily states may or may not produce behavior
problems. FurtheR, ACT suggests that attempts to control
these states may actually worsen mental health problems.
Strategies to control, eliminate, or suppress negative
states, called experiential avoidance, are directly targeted.
ACT seeks to treat the functional class of experiential
avoidance rather than specific diagnostic categories.
HoweveR, A C T has been applied to a number of DSM-IV
disorders. We detail the application of ACT to an adoles-
cent diagnosed with anorexia and comment on the treat-
ment implemented by Heffn~ Sperry, Eifert, and Det-
weiler (2002). We discuss the broad assessment issues
necessitated by the type of difficulties a patient with an-
orexia may have. The general structure of an ACT inter-
vention is elaborated on, including values, exposure,
defusion, and empowerment.
ACT Case Conceptualization
CEPTANCE AND COMMITMENT THERAPY (ACT) is a
A principles-driven, rather than procedure-driven,
treatment. The "doing" of ACT involves the organization
of the therapist's conceptualization a r o u n d a set of as-
sumptions. Particular interventions are dictated by their
consistency with this conceptualization. Because ACT has
a fundamentally different view of the role of cognition
and emotion in psychological problems, we will begin by
providing a brief overview.
Negative Cognition, Emotion, and Bodily States
in Popular Culture
Popular culture embraces the notion that positive
emotions, cognitions, and bodily states cause g o o d behav-
ior and negative emotions, cognitions, and bodily states
Cognitive and Behavioral Practice 9, 237-243, 2002
1077-7229/02/237-24351.00/0
Copyright © 2002 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
237
schools and workplaces teaching people to feel more
confident, to have higher self-esteem, and to be cheerful
and optimistic. Confidence, self-esteem, and optimism
are our psychological allies, while negative aspects of ex-
perience are to be controlled, reduced, or eliminated.
Negative Cognition, Emotion, and Bodily States
in Clinical Science
Models of psychopathology often accept the assump-
tion that negative thoughts and emotions must be sup-
planted with positive thoughts and emotions in order
that our clients might move on with their lives. In a num-
ber of therapies, clients are taught to dispute negative
thoughts (Beck, Rush, & Shaw, 1979; Ellis, 1962). Some
focus on elimination or reduction of problematic emo-
tional states, such as anxiety, through exposure (e.g., Bar-
low, Craske, Cerny, & Klosko, 1989). In treating substance
abuse, attempts are made to reduce conditioned cravings
through cue exposure (Monti, Adams, Kadden, & Cooney,
1989). All of these treatments share the view that certain
cognitions, emotions, and bodily states lead to bad behav-
ioral outcomes and that in order to improve the behavioral
outcomes, an array of problematic private events must be
eliminated, or at least reduced.
Negative Cognition, Emotion, and
Bodily States in ACT
From an ACT perspective, negative cognition, emo-
tion, and bodily states may, but need not, produce bad
behavioral outcomes. In addition, at least u n d e r some cir-
cumstances, attempts to eliminate negative emotion and
cognition seem to worsen mental health problems (and
physical health problems; see Pennebaker, 1997). The at-
tempt to reduce, eliminate, or decrease the probability of
experiencing a variety of avoided private e v e n t s - -
including painful thoughts, emotions, memories, and
bodily states--has been labeled experiential avoidance, and
the analysis of the detrimental effects of avoidance on be-
havioral functioning has been referred to as acceptance the-
0ry (Hayes, Strosahl, & Wilson, 1999; Hayes, Wilson, Gif-
ford, Follette, & Strosahl, 1996). In doing so, ACT takes
advantage of a growing body of literature that suggests
that attempts to suppress or avoid negative private events
may work to reduce those negative states over the short
term, but may actually worsen outcomes over the long
term. Although evidence is not wholly uniform, there is
considerable evidence in the experimental literature on
t h o u g h t suppression (Purdon, 1999, for recent review)
and in the coping literature a m o n g depressives, survivors
of child sexual abuse, alcoholism, and recovery from
traumatic events, suggesting that avoidant means o f cop-
ing predict poorer long-term outcomes (see Hayes et al.,
1996, for a review). ACT focuses on the role of experiential
238 Wilson & Roberts
avoidance in the e x a c e r b a t i o n a n d m a i n t e n a n c e o f a
n u m b e r o f psychological problems.
In the case o f this anorexic adolescent, ACT c o m p o -
nents were i n t e g r a t e d into m o r e traditional behavior
therapy techniques (Heffner, Sperry, Eifert, & Detweiler,
2002). Such integration is a p p r o p r i a t e , since ACT is, at its
heart, a behavioral treammnt. Problems can emerge when
strategies from alternative behavioral perspectives con-
tradict an ACT orientation; however, careful analysis can
often resolve differences by eliminating or refraining
c o m p o n e n t s t h a t m i g h t w o r k at c r o s s - p u r p o s e s with
a c c e p t a n c e - o r i e n t e d strategies.
ConsideL for example, the use o f relaxation strategies
for anxiety problems. A n u m b e r o f ACT experiential ex-
ercises involving e x p o s u r e to t r o u b l i n g thoughts a n d
e m o t i o n s begin with c o m p o n e n t s a i m e d at i n d u c i n g a
state o f focused relaxation. Relaxation is n o t p u r s u e d as
an e n d in itself. Instead, relaxation is a means to effective
exposure. T h e r e is g o o d empirical evidence that this
should be useful. Borkovec has d e m o n s t r a t e d that worry
p r o d u c e s a u t o n o m i c inflexibility, a n d that individuals
show facilitation o f h a b i t u a t i o n when e x p o s u r e is pre-
c e d e d by a p e r i o d o f relaxation r a t h e r than worry (Bor-
kovec & Hu, 1990). In this instance, the relaxation actu-
ally facilitates a u t o n o m i c flexibility (and arousal) in the
e x p o s u r e session a n d thus makes for a m o r e effective ex-
tinction trial. T h e p u r p o s e o f the relaxation in ACT is
not to p r o d u c e m o r e relaxation a n d less arousal in the
presence o f the avoided event. Instead, relaxation is in-
t e n d e d to facilitate flexibility, arousal, a n d m o r e effective
exposure.
ACT a s a H e a l t h - O r i e n t e d P e r s p e c t i v e
Most o f clinical psychology, a n d most o f the mental
health professions, have e m b r a c e d pathology-oriented
views o f h u m a n suffering. Suffering, such as pervasive
negative thinking, sad or anxious mood, is considered "ab-
normal" and "pathological." T h e j o b o f therapy and thera-
pist is to extract the pathology, leaving a healthy, well-
functioning individual. In the instance o f the y o u n g
woman treated by H e f f n e r et al. (2002), "fat thoughts"
would be part o f the p a t h o l o g y to be removed. F r o m this
perspective, the "normal" state for h u m a n s is to be free o f
worry, negative cognition, negative memory, anxiety, a n d
sadness. This version o f n o r m a l i t y has b e e n called the
"assumption o f healthy normality" (Hayes et al., 1999).
Howevel, t h e r e is c o n s i d e r a b l e evidence that suggests
that suffering, far from being abnormal, is quite perva-
sive. T h e National Comorbidity Study, for example, esti-
m a t e d the 1-year prevalence o f DSM Axis I disorders at
29% (Kessler et al., 1994). This prevalence rate does not
even take into consideration the many thousands o f indi-
viduals who are u n h a p p y in their work, marriages, family,
a n d social relations. These a n d o t h e r data suggest that
h u m a n suffering is in fact quite pervasive.
ACT is n o t a t r e a t m e n t for DSM categories. ACT does
not seek to remove anything. Rather, ACT is a t r e a t m e n t
for experiential avoidance a n d seeks to ameliorate avoid-
ance in the service o f increasing the client's capacity to
engage in a rich a n d meaningful life. Regardless o f the
formal p r o p e r t i e s o f an individual client's difficulties, we
focus on the individual's life direction, a n d interventions
are d i r e c t e d a n d dignified by that agenda. In the case o f
this y o u n g woman, we would assess some quite traditional
domains; however, o u r organization of resulting assess-
m e n t findings will be in a c c o r d a n c e with a h e a l t h - a n d
d e v e l o p m e n t - o r i e n t e d case conceptualization.
Diagnostics and Assessment i n ACT
Developers o f ACT have b e e n skeptical o f the validity
of DSM diagnostic categories a n d have suggested func-
tional diagnostic dimensions as an alternative (e.g., expe-
riential avoidance; Hayes et al., 1999; Hayes et al., 1996).
The validity o f categories aside, however, there are con-
siderable data suggesting that individuals with p r o b l e m -
atic eating patterns classified as a n o r e x i a often have a va-
riety o f o t h e r psychosocial a n d physical difficulties, a n d
these co-occurring difficulties ought to be assessed a n d in-
cluded in an ACT case conceptualization. Assessment is
d o n e in o r d e r to g a t h e r evidence o f the effects o f the cli-
ent's attempts to control negative private experience.
Medical Correlates
Anorexic clients should to be assessed for a variety o f
medical conditions r a n g i n g from cardiovascular disor-
ders to e n d o c r i n o l o g i c a l dysfunction. Routine medical
e x a m i n a t i o n of anorexic clients should include c o m p l e t e
physical examination, s t a n d a r d laboratory tests, chemical
analysis, b l o o d count, a n d urinanalysis (Foreyt & Mikhail,
1997). T h e high lethality, as n o t e d by the authors, indi-
cates the i m p o r t a n c e a n d n e e d for a full medical workup
p r i o r to t r e a t m e n t (Mehler & A n d e r s e n , 1999). Any med-
ical p r o b l e m s that have arisen will be i n c l u d e d in the
t r e a t m e n t in two ways. First, medical p r o b l e m s will be
b r o u g h t into t r e a t m e n t as examples o f the unworkability
of control. Mortality is a particularly glaring e x a m p l e o f
unworkability. Second, medical p r o b l e m s will be exam-
i n e d with respect to their i n t e r f e r e n c e with the client's
ability to pursue h e r values.
For example, as a c o n s e q u e n c e o f h e r p a r e n t s ' a n d
coach's health concerns, Emily h a d lied a b o u t food in-
take. This i n c i d e n t provides a g o o d e x a m p l e o f the cas-
cading o f negative events in the service o f control. T h a t
is, the client starves herself in o r d e r to control "fat
thoughts." As the client becomes dangerously thin, im-
p o r t a n t adults in h e r life begin questioning h e r a b o u t h e r
 Response: Principles of ACT Applied to Anorexia
eating. In order to prevent negative interactions with
these adults while retaining control over her diet, she lies
to these individuals. Their interpersonal closeness thus
cluttered by this obfuscation, the client is now likely to
suffer strained social relations. Psychosocial outcomes
might include the client feeling less support, more iso-
lated, and not well understood. Her health will continue
to deteriorate, precipitating even more conflict. In the
context of examining medical consequences, we would
carefully explore these psychosocial consequences.
Psychosocial Correlates
Mood and cognition. A wide variety of psychosocial cor-
relates of anorexia have been found. Obsessional and
phobic anxiety symptoms are a prominent, and often
overlooked, feature of anorexia (Rasmussen & Eisen,
1994). Studies have demonstrated that 66% of eating dis-
ordered clients self-report clinically significant depres-
sion (Cumella, Wall, & Kerr-Almeida, 1999). Dancyger,
Sunday, Eckert, and Halmi (1997) f o u n d that p o o r out-
comes following inpatient treatment for eating disorders
were associated with higher self-reported symptomatol-
ogy. The ACT therapist should note the client's attempts
to control negative cognition and affect and all of the var-
ious forms control takes. Chief a m o n g control strategies
with this client will be her attempts to control "fat
thoughts" and unfavorable comparisons with peers by
self-starvation. Assessment in the domain o f m o o d and
cognition will focus on the client's attempts to control
these features of experience and whether, over the long
term, these control strategies have worked. We would ask
the client whether problems with m o o d and cognition
seem to be getting better or worse over time.
Weight regulation. The preoccupation with weight and
thinness has been noted as a hallmark symptom of an-
orexia. The assessment of weight should include data col-
lection on weight history and the preoccupation with
weight: for instance, current weight and height, ideal
weight, and the range of weight since onset of adoles-
cence. Also important are any changes in weight associ-
ated with major life events (Foreyt & Mikhail, 1997). The
client's, as well as the family's, attitudes about weight loss
are potential sources of pertinent data. Cognitions about
weight will be p r o m i n e n t targets for ACT interventions
aimed at loosening their control over the client's eating
patterns. Exercise has also been shown to be ritualistic in
clients with anorexia and may play a role in the develop-
m e n t or maintenance of the disorder. Again, the use of
exercise to control negative thoughts about weight gain
should be explored with regard to long-term workability.
That is, have starvation and excessive exercise eliminated
these negative thoughts on a long-term basis?
Body image. Disturbance in feelings and attitudes to-
ward one's body and a disturbed physical picture of one's
239
body have been show to be predictive of relapse following
treatment for eating disorders in adolescents (Fabian &
Thompson, 1989). Therefore, the use of either standard-
ized self-report form, professional ratings, or client esti-
mations of physical size can be used to measure body image
disturbances.
Social skills. Anorexics have long been shown to have
difficult interpersonal relationships. Crisp, Hsu, Hard-
ing, and Hatshorn (1980) found that clients with anorexia
had high rates of excessive shyness as children, difficul-
ties playing with other children, or no friends during
childhood. Any social inhibition will be examined, again,
with a focus on life goals and workability.
Treatment From an ACT Perspective
The general structure of an ACT intervention is as
follows:
I. Assessment of relevant contextual, psychological,
and behavioral p h e n o m e n a .
2. Creative hopelessness: exploration of the experi-
ence of unworkability in the client's life.
3. Values assessment: exploration of the client's
valued life-direction (s).
4. Control as the problem: focus on the ways that con-
trol strategies in general can backfire and a special
focus on the ways that the dysfunctional control
agenda is interfering with the client's ability to live
in accord with his or her values.
5. Self-as-context: making contact with a sense of self
that is independent of the contents of consciousness.
6. Commitment: making and keeping behavioral
commitments that move the client forward in terms
of his or her values.
7. Exposure, cognitive defusion, and repertoire
building in the service of advancing a valued life di-
rection (including exposure to external events, but
especially attending to exposure to private experi-
ence such as emotion, cognition, memory, and
bodily states, a m o n g others).
ACT has been described in detail in both book and ar-
ticle form (Hayes et al., 1999; Hayes & Wilson, 1994; Wil-
son, Hayes, & Byrd, 2000). The above ordering differs
somewhat from the ordering originally outlined in Hayes
et al. It is consistent with some more recent discussions
(e.g., Wilson et al., 2000). The major difference in orga-
nization involves moving the values c o m p o n e n t to an ear-
lier position in the order of treatment components. Al-
t h o u g h no clinical trial has been executed examining
different ordering of treatment components, we have
varied their order in training and treatment contexts,
and our current clinical impressions are that the values
components need to be more explicitly implemented early
240 Wilson&Robe,s
in treatment. While this impression o u g h t not be given
u n d u e weight, there are theoretical reasons to expect
that this o r d e r might be useful. Valued ends can provide
an i m p o r t a n t motivational factor for treatment. Some-
times t r e a t m e n t is more painful than no treatment. For
example, in the short term, exposure is more painful
than avoidance. Values c o m p o n e n t s dignify the difficulty
of treatment a n d might reasonably improve t r e a t m e n t re-
tention. The values e l e m e n t originated in the context of
a National Institutes o n Drug Abuse protocol develop-
m e n t grant explicitly because of the difficulties i n h e r e n t
in seeing chronic substance abusers t h r o u g h very painful
early phases of detoxification. Developers of ACT have
suggested (Hayes et al.) that therapists ought to use the
ACT technology with flexibility, d e p e n d i n g u p o n the
needs of the individual client, treatment setting, a n d du-
ration, a m o n g other relevant factors. Until these matters
are settled empirically, we must proceed with what is the-
oretically sensible. In what follows, we will not address
each of the steps of t r e a t m e n t in order, as described
above a n d elaborated elsewhere. Instead, we will focus o n
four domains that require attention through all phases of
treatmen t:
• values
• exposure
• defusion
• empowerment
As long as other interventions do n o t violate these
core assumptions, they can be i n t e r m i x e d with ACT-
oriented interventions, We will c o m m e n t o n the Heffner
et al. (2002) case presentation as we discuss each domain.
We will also discuss problems that co-occur in such cases
b u t that were n o t directly addressed in this particular case
study (e.g., m o o d problems a n d social anxiety).
Values
Although there are phases of treatment in which the
exploration of values is the focus of treatment, they ought
to be touched u p o n in every session. D u r i n g the first few
sessions, the values c o m p o n e n t may be as simple as sug-
gesting to the client that t r e a t m e n t will be directed by the
client's values. Even if those values are obscured by a long
battle with anxiety, depression, alcoholism, or an eating
disorder, the therapist can still suggest that the therapy
will be a b o u t revealing a n d moving in the direction of
this obscured personal sense of life direction. We suggest
that therapists n o t leave the session without this being
clear. The t r e a t m e n t is a b o u t the client a n d advancing a
life that is valued.
In the case of Emily, Heffner et al. (2002) show good
sensitivity to the centrality of values in ACT-oriented
treatment. We were particularly impressed with their use
of concrete a c c o m p a n i m e n t s to standard ACT meta-
phors. The use of these physical complements, such as
the values map a n d the finger puzzle used in this case, ap-
pears to help clients grasp the m e a n i n g of the metaphors.
Use of these physical metaphors is entirely consistent
with the ACT perspective of relying o n experiential ther-
apeutic c o m p o n e n t s rather than merely using words.
Moving forward in valued areas of living can provide a
context for other sorts of difficulties that may coincide
with anorexia. For example, m o o d problems are helped
by behavioral activation (Babyak et al., 2000; Salmon,
2001). Behavioral activation in an area explicitly valued
by the client can provide a natural rather than contrived
form of activity. The h e i g h t e n e d activity should improve
m o o d a n d is likely to put the individual in contact with
other reinforcers that accrue to such activities. Heffner et
al. (2002) exploited this y o u n g woman's interest in an
eventual career in veterinary medicine. This interest
could be pursued even further if the client showed suffi-
cient interest. For example, if this y o u n g woman were to
be e n c o u r a g e d to volunteer with the local h u m a n e soci-
ety or other organized animal rescue activities, she would
likely become involved socially with other like-minded
persons. Her contributions might be recognized formally
or informally. Such social interactions could also provide
the context for exposure to social situations, particularly
relevant in the case of anorexics who display shyness. A
client is more likely to comply with (and m a i n t a i n post-
treatment) tolerating an u n c o m f o r t a b l e social situation
in the service of something she cares about than a social
situation contrived for its own sake.
Exposure
ACT is a behavioral t r e a t m e n t a n d relies o n an under-
standing of basic behavioral processes. O n e can think of
experiential avoidance as a sort of "experience phobia"
(Wilson, 1997). The behavioral prescription for phobic
avoidance is exposure. Behavior therapists have focused
on two aspects of exposure that are important, b u t n o t
sufficient, in u n d e r s t a n d i n g the role of exposure in ACT.
Classical c o n d i t i o n i n g analogues of phobias emphasize
c o n d i t i o n e d elicitation a n d c o n d i t i o n e d avoidance. Sup-
pose, for example, we expose a rat to a tone followed by a
shock o n repeated trials. Two outcomes are likely. First,
the rat will show c o n d i t i o n e d elicitation in the presence
of the tone. The rat may show increased a u t o n o m i c
arousal. It may freeze, defecate, a n d urinate. Second, the
rat will work to avoid the tone. Experimental work on ex-
posure a n d its effects have carefully e x a m i n e d decre-
ments in c o n d i t i o n e d elicitation a n d c o n d i t i o n e d avoid-
ance over repeated u n r e i n f o r c e d trials. As a result of
u n r e i n f o r c e d trials, elicitation a n d avoidance dissipate in
an orderly fashion.
In ACT we focus less o n r e d u c i n g these particular
outcomes, however, a n d more o n the client's range a n d
 Response: Principles of ACT Applied to Anorexia
flexibility in responding. In a d d i t i o n to avoidance a n d
elicitation going up, the rat's behavioral r e p e r t o i r e be-
comes very narrow with respect to the c o n d i t i o n e d stimu-
lus (the tone). Similarly, p e o p l e can b e c o m e quite nar-
row in their range a n d flexibility in response to aspects o f
their own e x p e r i e n c e such as "negative" thoughts, emo-
tions, memories, a n d bodily states, a m o n g others. T h e
sexual abuse survivor may b e c o m e distressed a n d dissoci-
ate when m e m o r i e s of abuse occur d u r i n g sex. T h e d r u g
a d d i c t may e n g a g e in very rigid patterns o f d r u g seeking
a n d use drugs in response to aversive withdrawal states
a n d cravings. In this case, the client engages in a rigid
p a t t e r n o f self-starvation in o r d e r to alleviate u n p l e a s a n t
thoughts r e g a r d i n g h e r body. T h e issue from an ACT per-
spective is the lack of flexibility in response to these aver-
sive thoughts a n d feelings associated with weight gain
a n d b o d y image, n o t their presence.
In ACT we are n o t so m u c h interested in eliminating
an u n h e a l t h y response from the client's r e p e r t o i r e as we
are interested in b r o a d e n i n g the array of potential re-
sponses. We d o n ' t want the snake p h o b i c to be u n a b l e to
flee the presence of a snake. We do want to be able to im-
pact the fact that they m u s t flee. Similarly, we do n o t want
to rid the anorexic o f the capacity to refuse food when
she has thoughts a b o u t b e i n g f a t - - w e all do that at times.
Rather, we h o p e to b r o a d e n h e r r e p e r t o i r e with respect
to these thoughts. We would like to alter the fact that she
m u s t refuse food.
Psychological c o n t e n t that e m e r g e s in the context of
the pursuit o f valued life goals, a n d which precipitates
u n h e a l t h y avoidance, should be targeted for exposure.
T h e nature of the e x p o s u r e work will n o t merely be re-
m a i n i n g in the presence o f the feared psychological con-
tent, b u t in b u i l d i n g m o r e e l a b o r a t e d response reper-
toires with respect to that content, the latter of which is
an o p e r a n t a p p r o a c h to avoidance. A variety o f therapeu-
tic strategies, i n c l u d i n g m e t a p h o r s , experiential exer-
cises, a n d verbal conventions, can make avoidance o n e
a m o n g an array of responses to painful o r frightening as-
pects of the client's experience. Experiential exercises in-
volving e x p o s u r e to "fat thoughts" would be a p p r o p r i a t e ,
a n d importantly, are always f r a m e d in terms o f b u i l d i n g
flexibility in the service of taking a valued direction in
life. As described in the previous section, o t h e r difficult
e m o t i o n a l content, such as d e p r e s s e d m o o d , food obses-
sions, o r shyness, o u g h t also be t a r g e t e d for exposure-
based interventions.
Defusion
Delusion refers to a set o f techniques, b u t also to a
general posture a d o p t e d by the therapist. A l t h o u g h a full
discussion is b e y o n d the scope o f this article, a c c o r d i n g
to the theory of verbal behavior u n d e r l y i n g ACT, verbal
functions so d o m i n a t e o u r r e s p o n d i n g that n o o t h e r
241
functions o f a stimulus are available (Hayes & Wilson,
1993; Wilson & Blackledge, 2000; Wilson & Hayes, 2000;
Wilson, Hayes, Gregg, & Zettle, 2001). Thus, we r e s p o n d
to words a b o u t some event as if we were r e s p o n d i n g to
the actual event the words describe. For e x a m p l e , a
t h o u g h t may be r e s p o n d e d to as what it says it is, b u t it
can also be r e s p o n d e d to as a thought. To provide a con-
crete example, if this client h a d the thought, "I can't
stand b e i n g fat," a n d r e s p o n d s only to the literal c o n t e n t
of that thought, they m u s t do s o m e t h i n g to alter that state
o f affairs. This m e a n s starving o n e s e l f to alleviate the in-
sufferable state. However, in session, the client could be
c o a c h e d to restate the sentence as, "I am having the
t h o u g h t that I c a n ' t stand b e i n g fat." Such locutions,
while awkward, highlight the fact that "I c a n ' t stand b e i n g
fat" is a thought. T h e t h o u g h t could also b e e x p e r i e n c e d
a n d n o t i c e d as a t h o u g h t in an eyes-closed experiential
exercise. This posture is akin to certain forms o f medita-
tion, as in the soldiers in the p a r a d e exercise d e s c r i b e d by
Heffner et al. (2002; Hayes et al., 1999). T h e t h o u g h t
c o u l d be said out l o u d a h u n d r e d times rapidly. It c o u l d
be written on a card a n d p l a c e d in the p e r s o n ' s pocket, or
on two d o z e n cards. T h e person could tell four stories
a b o u t a person who h a d that thought: o n e that t u r n e d
o u t tragically, one that t u r n e d out absurdly, o n e that was
boring, a n d one that t u r n e d out heroically. T h e p o i n t o f
these exercises is twofold. First, they provide repertoire-
b u i l d i n g exposure as described in the previous section.
A n d second, these interventions loosen the d o m i n a n t ver-
bal functions that make such a t h o u g h t so life restricting.
As a general principle a n d posture for the ACT thera-
pist, we never r e t r e a t from f r i g h t e n i n g psychological con-
tent when that c o n t e n t is between the client a n d a life the
client desires. T h e therapist takes a somewhat meditative
a n d serious (and p e r h a p s playful) posture with respect to
the avoided content. In d o i n g so, the therapist m o d e l s
a n d facilitates the client's ability to develop new a n d flex-
ible responses to old p r o b l e m a t i c psychological content.
Because this client showed c o n t i n u e d elevation in b o d y
dissatisfaction, thoughts a n d e m o t i o n s related to this do-
m a i n would be particularly g o o d targets for b o t h expo-
sure a n d d e l u s i o n strategies. These aspects of the client's
psychological life are n o t currently driving any p r o b l e m -
atic b e h a v i o r - - a s evidenced by h e r weight gain. How-
ever, they may be potential p r o b l e m areas u n d e r stressful
conditions. As a prophylactic to relapse, therapy s h o u l d
pay special attention to b u i l d i n g flexibility with respect to
thoughts a n d e m o t i o n s associated with body satisfaction.
Empowerment
ACT is a client-centered treatment. It relies o n the cli-
ent's values to give it direction, on a dense u n d e r s t a n d i n g
o f the client's e x p e r i e n c e a n d struggle to provide the
c o n t e n t for e x p o s u r e a n d defusion interventions, a n d on
24Z Wilson & Roberts
t h e c l i e n t ' s c o m m i t m e n t to g r o w t h a n d d e v e l o p m e n t to
m a k e t h e r a p e u t i c g a i n s possible. T h e A C T t h e r a p i s t
w o r k s p e r s i s t e n t l y to u n d e r m i n e t h e t h e r a p i s t ' s p e r c e i v e d
p o w e r to c h a n g e t h e client, a n d systematically e m p h a -
sizes t h e c l i e n t ' s c o n t r i b u t i o n s to t r e a t m e n t p r o g r e s s . I n
e a c h session, t h e t h e r a p i s t s h o u l d a c k n o w l e d g e a n d so-
licit t h e c l i e n t ' s i n p u t i n t o t h e d i r e c t i o n a n d p a c e o f treat-
m e n t . O f c o u r s e , c l i e n t s will s o m e t i m e s s u f f e r f r o m a n
u n w i l l i n g n e s s to take r e s p o n s i b i l i t y f o r t h e i r t r e a t m e n t
a n d t h e i r lives, o r a b e l i e f t h a t t h e y a r e i n c a p a b l e o f s u c h
responsibility. I f t h e t h e r a p i s t r e s p o n d s to this a c t e d - o u t
i n c o m p e t e n c e by t a k i n g c o n t r o l a n d responsibility, t h e y
will h a v e c o n f i r m e d t h e c l i e n t ' s w o r s t fears. T h e A C T
t h e r a p i s t is a c o n s i s t e n t s o u r c e o f active c o n f i d e n c e t h a t
t h e c l i e n t c a n a n d will take a d i r e c t i o n in t r e a t m e n t . T h i s
is e x p r e s s e d b o t h i n w o r d a n d in d e e d . We tell o u r c l i e n t s
t h a t we b e l i e v e t h a t t h e y c a n a n d will take a d i r e c t i o n , a n d
we actively rely o n it in t r e a t m e n t .
I n t h e case o f this a n o r e x i c y o u n g w o m a n , a t t e m p t s to
c o n t r o l h e r b e h a v i o r f r o m o u t s i d e s o u r c e s , s u c h as h e r
p a r e n t s a n d s w i m m i n g c o a c h , r e s u l t e d in n o n c o m p l i a n c e
a n d m i s r e p r e s e n t a t i o n o f h e r f o o d i n t a k e . W o r k i n g alli-
a n c e h a s b e e n d e m o n s t r a t e d r e p e a t e d l y to b e a n i m p o r -
t a n t v a r i a b l e in successfnl t r e a t m e n t ( M a r t i n , G a r s k e , &
Davis, 2000). Use o f a u t h o r i t y to c o n t r o l b e h a v i o r is p r o b -
ably b e s t a v o i d e d , e s p e c i a l l y with a d o l e s c e n t s w h o o f t e n
h a v e a low t o l e r a n c e f o r c o m m a n d s . H a v i n g t h e d i r e c t i o n
o f t r e a t m e n t d i c t a t e d by this y o u n g w o m a n ' s o w n values
b o t h d e f u s e s t h e l i k e l i n e s s o f u n h e a l t h y r e a c t i o n s to au-
t h o r i t y a n d v a l i d a t e s h e r s e n s e o f h e r s e l f a n d h e r ability to
set a d i r e c t i o n i n h e r life.
Conclusion
W e h a v e s u g g e s t e d t h a t a n e x p e r i e n t i a l a v o i d a n c e per-
s p e c t i v e h a s b r o a d applicability, a n d t h a t ACT, as a treat-
m e n t t b r e x p e r i e n t i a l a v o i d a n c e , o u g h t to likewise h a v e
b r o a d applicability" ( H a y e s e t al., 1999; H a y e s e t al., 1996).
U l t i m a t e l y , however, t h e g e n e r a l i t y o f t h e p r i n c i p l e s u n -
d e r l y i n g A C T a n d t h e a p p l i c a b i l i t y o f A C T t e c h n o l o g y to
diverse areas of human suffering remains an empirical
m a t t e r . W e a r e p l e a s e d to see c o h e r e n t a n d f l e x i b l e appli-
c a t i o n s o f A C T to n e w d o m a i n s . I n p a r t i c u l a r , t h e i n t e g r a -
t i o n o f A C T i n t e r v e n t i o n s with i n t e r v e n t i o n s o f well-
e s t a b l i s h e d efficacy h a s t h e p o t e n t i a l to a n s w e r q u e s t i o n s
a b o u t ways to i m p r o v e t r e a t m e n t , r a t h e r t h a n m e r e l y
w h e t h e r s o m e t r e a t m e n t works.
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Address correspondence to Kelly G. Wilson, Department of
Psychology, 205 Peabody Building, University of Mississippi, Oxford,
MS 38655; e-mail: kwilson@olemiss.edu.
Received: March 1, 2001
Accepted: June 8, 2001
Response Paper
Experiential Avoidance, Cognitive Fusion,
and an ACT Approach to
Anorexia Nervosa
S t e v e n C. H a y e s a n d J u l i e a n n P a n k e y
University o f N e v a d a , Reno
Case conceptualization and treatment planning for indi-
viduals with eating disorders seem tofollow logicaUyfrom
within the framework of Acceptance and Commitment
Therapy (ACT), which focuses on maladaptive control
strategies directed toward emotional avoidance, cognitive
fusion, and failure to act in accord with chosen values.
The use of A C T in this case is discussed with recommen-
dations for further A C T intervention strategies, why an
A C T conceptualization makes sense with this population,
and anticipated issues to consider.
Presenting Problem and Diagnosis
MILY is an adolescent female who is p r e s e n t i n g with
E behaviors indicating a n o r e x i a nervosa, restricting
type. She evidences behavioral c o n t r o l strategies such as
restricted dietary intake, m i s r e p r e s e n t a t i o n o f food in-
take, a n d excessive weighing o f herself. Physiologically,
Emily evidences excessive weight loss l e a d i n g to a Body
Cognitive and Behavioral Practice 9, 243-247, 2002
1077-7229/02/243-24751.00/0
Copyright © 2002 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
243
Mass I n d e x below a c c e p t e d figures for b e i n g under-
weight ( < 18), fatigue, a n d loss of monthly menses. Assess-
m e n t data from the Eating Disorder I n v e n t o r y - 2 (EDI-2)
indicate that Emily's scores on drive for thinness, ineffec-
tiveness, a n d body dissatisfaction scales were in the an-
orexic, restricting type, range.
Assessment
T h e ACT conceptualization o f most psychological
p r o b l e m s can be s u m m a r i z e d in the following points:
• Experiential avoidance: Most psychological difficulties
have to do with the unnecessary avoidance a n d ma-
n i p u l a t i o n of private events.
• Cognitive fusion: This avoidance emerges from the
d o m i n a t i o n of verbal regulation over o t h e r b e h a v i o r
regulatory processes.
• Contextual control: Both e x p e r i e n t i a l avoidance a n d
cognitive fusion are contextually c o n t r o l l e d a n d
thus the goal of ACT is to alter these destructive
contexts.
• The solution is the problem: To take a new direction,
we must let go o f an old one. If a p r o b l e m is
chronic, the client's "solutions" are p r o b a b l y p a r t o f
the p r o b l e m .
• Value action is the goal'. T h e value of any action is its
workability m e a s u r e d against the client's true values
(those he o r she would have if it were a free choice).
T h e b o t t o m line issue is living well, n o t having small
sets o f "good" feelings.
Emily presents with classic behaviors related to restrictive-
type eating disorders. T h e specific features of assessment
in this case are d e t e r m i n e d by that g e n e r a l p r o b l e m do-
main. Based on the ACT a p p r o a c h to psychological prob-
lems j u s t delineated, the initial ACT assessment always
includes an a t t e m p t to d e l i n e a t e p r e s e n t a n d historical
maladaptive control strategies d i r e c t e d toward experien-
tial avoidance, ways that verbal formulations may be domi-
nating direct experience, a n d the contextual supports for
both. Particular care is given to seeing whether the pre-
senting p r o b l e m is a "solution" g o n e awry, l i n k e d to expe-
riential avoidance a n d cognitive fusion.
It is clear that this p a t i e n t has b e c o m e e n t a n g l e d in
negative cognitions a r o u n d body image a n d image o f
self, a n d is trying to regulate the u p s e t p r o d u c e d by these
thoughts t h r o u g h a n o r e x i a itself. We d o n o t know m u c h
a b o u t o t h e r forms of experiential avoidance o r their his-
tory. It is c o m m o n in these kinds o f p r o b l e m s for eating
regulation to be linked to o t h e r forms o f e m o t i o n a l
avoidance, such as regulating u p s e t felt over conflicted
family relationships. A detailed list o f every m e t h o d the
patient has used to "try to solve their problems" will usu-
ally link back to this history, a n d will provide useful