232

COGNITIVE B E H A V I O R A L CASE C O N F E R E N C E

A c c e p t a n c e a n d C o m m i t m e n t Therapy in the Treatment of an A d o l e s c e n t

Female With Anorexia Nervosa: A Case Example
M i c h e l l e H e f f n e r , J e a n n i e S p e r r y , G e o r g H. E i f e r t , a n d M i c h a e l D e t w e i l e r , West Virginia University

Acceptance and Commitment Therapy (ACT) is a cognitive-behavioral treatment that targets ineffective conOvl strategies and experi-
ential avoidance--the unwiUingness to accept negative thoughts, feelings, and emotions. Although A C T has been suggested as an
effective treatment for panic, substance use, pain, and mood disorders, there are no published reports on the use of A C T for treating
adolescent disorders such as anorexia nervosa. This case summarizes the successful adoption of A C T techniques in the treatment of a
15-year-oldfemale with anorexia nervosa. It also shows how ACT techniques can be successfully combined with, and set the stage for,
more standard cogv~itive-behavioral interventions.

OREXIA NERVOSA is a serious psychological c o n d i t i o n
N in which an individual fails to maintain a minimally
n o r m a l body weight, has an intense fear o f weight gain,
a n d perceives body weight or shape inaccurately. Adoles-
c e n t females are most at risk for d e v e l o p i n g the disorder,
with onset as early as age 14. Early d e t e c t i o n a n d inter-
vention are essential, as the d i s o r d e r b e c o m e s m o r e diffi-
cult to treat as it progresses (Bulik, 1998). A n o r e x i a can
lead to several serious health consequences, such as kid-
ney damage, cardiovascular problems, a n d osteoporosis.
In severe cases, d e a t h can result from multiple organ fail-
ure or electrolyte imbalance. The aggregate mortality
rate for a n o r e x i a has been estimated at .56% p e r year,
which is 12 times greater than the a n n u a l death rate due
to all causes o f d e a t h for 15- to 24-year-old females in the
general p o p u l a t i o n (Sullivan, 1995).
In spite o f these potential life-threatening conse-
quences of anorexia, the d e v e l o p m e n t o f effective cogni-
tive-behavior therapy (CBT) for a n o r e x i a is still o n g o i n g
(Wilson, 1999). A l t h o u g h several well-established CBT
manuals a n d empirically validated treatments exist for
treating bulimia nervosa a n d binge eating (Agras & Ap-
ple, 1997; Fairburn, Marcus, & Wilson, 1993; Thackwray,
Smith, Bodfish, & Meyers, 1993; Wilfley, Agras, Telch, &
Rossiter, 1993), these particular treatxnents are n o t suit-
able for anorexia. Despite the absence of any published
CBT manuals for treating anorexia, interventions have
typically e m p l o y e d some form o f selt:monitoring a n d
contingency m a n a g e m e n t . Self-monitoring requires the
p a r t i c i p a n t to detail eating behaviors a n d the contexts in
which they occur to index t r e a t m e n t progress a n d guide
contingency p l a n n i n g (Wilson & Vitousek, 1999). Based
on this information, a contingency plan can be set up to
Cognitive and Behavioral Practice 9, 2 3 2 - 2 3 6 , 2002
1077-7229/02/232-23651.00/0
Copyright © 2002 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
provide access to reinforcers after eating a n d to remove
contexts o r events that trigger self-starvation.
In spite o f these efforts, anorexia remains a difficult
d i s o r d e r to treat. O n e recently-developed CBT p r o g r a m ,
A c c e p t a n c e a n d C o m m i t m e n t T h e r a p y (ACT; Hayes,
Strosahl, & Wilson, 1999), may be useful in the t r e a t m e n t
o f a n o r e x i a because this cognitive-behavioral t r e a t m e n t
targets core p r o b l e m s in anorexia: ineffective control
strategies a n d the unwillingness to r e m a i n in contact with
negative emotions o r thoughts (experiential avoidance).
O n e c o m p o n e n t o f ACT is to e x a m i n e control strategies
as problems, n o t solutions. This fits well with a r e c e n t
cognitive-behavioral theory o f anorexia, which proposes
that a p r o b l e m a t i c n e e d for control maintains this eating
d i s o r d e r (Fairburn, Shafran, & Cooper, 1999) a n d that
dietary restriction is r e i n f o r c e d by the sense o f being in
control, particularly if the individual has failed at control-
ling o t h e r areas o f life. A n o t h e r feature o f a n o r e x i a is the
avoidance of thoughts or feelings related to weight a n d
body image. In a r e c e n t study e x a m i n i n g the relation be-
tween cognitive avoidance a n d d i s o r d e r e d eating, college
women who scored high on two Eating Disorders Inven-
tory (EDI-2; Garner, 1991) subscales took l o n g e r to pro-
cess threat-related words (e.g., fail) than w o m e n with
lower EDI-2 scores (Meym, Waller, & Watson, 2000). This
suggests that experiential avoidance may play a role in
eating disorders, and food restriction could be the an-
orexic's a t t e m p t to avoid or reduce negative weight or
body image thoughts.
An ACT a p p r o a c h to t r e a t m e n t makes no a t t e m p t to
change o r eliminate avoidance agendas, but instead en-
courages acceptance o f b o t h e r s o m e thoughts a n d feel-
ings. An ACT t r e a t m e n t plan seeks to u n d e r m i n e ineffec-
tive control and avoidance strategies by h e l p i n g the client
identify valued life directions a n d providing the client
with s u p p o r t to achieve them. Thus, negative emotions
and thoughts are not obstacles but an expected part of goal-
directed behavior. In this way, clients learn to reco~lize a n d
 Act and Anorexia 233

Table 1 ioral medicine. Weekly o u t p a t i e n t t r e a t m e n t followed by

Overview of Core ACT Treatment Strategies m o n t h l y c h e c k u p s were c o n d u c t e d f r o m N o v e m b e r
1999 to July 2000. A total of 18 sessions were c o n d u c t e d at
Component/Strategy Goal/Purpose
the Q u i n Curtis C e n t e r (QCC), l o c a t e d in the Depart-
1. Creative hopelessness Client views avoidant solutions as m e n t o f Psychology at West Virginia University. T h e QCC
problems by employing paradox p r o v i d e s g e n e r a l m e n t a l h e a l t h services a n d t r e a t m e n t
and metaphors to disrupt ongoing
by g r a d u a t e s t u d e n t therapists s u p e r v i s e d by l i c e n s e d
avoidance repertoires.
2. Control is the problem Client explores ways in which psychologists.
avoidance behavior inhibits life
functioning. Patient Characteristics: History and Assessment
3. Self as context Client discriminates between oneself Emily, a 15-year-old Caucasian female, was b r o u g h t to
and one's problem behavior;
t r e a t m e n t by h e r m o t h e r a n d d i a g n o s e d with a n o r e x i a
provides context in which
acceptance is possible and nervosa, restricting type. She resided in a middle-class
avoidance is unnecessary. family with b o t h biological parents a n d h e r 13-year-old
4. Choosing a valued Client actively determines valued life brother. Emily's level of functioning was high, a n d she
direction directions. h a d n o p r i o r history of psychopathology. At the time of
5. Letting go of struggle/ Client experiences symptoms without
the intake, Emily's h e i g h t was 1.7 m a n d h e r weight was
embracing symptoms avoidance; facilitates contact with
direct contingencies by 51 kg (Body Mass I n d e x < 1 8 ) . H e r menstrual cycle h a d
encouraging client to deliberately b e e n absent for 3 months.
experience avoided thoughts and A p p r o x i m a t e l y 11 m o n t h s p r i o r to h e r p r e s e n t a t i o n at
feelings. the clinic, Emily b e g a n to notice the "thinness" of h e r fe-
6. Behavior change Client progresses toward committed,
male classmates. She b e c a m e dissatisfied with h e r b o d y
commitment valued directions.
a n d b e g a n to diet a n d occasionally refused to eat for an
entire day. She d e v e l o p e d a m o r b i d fear o f gaining
weight a n d weighed herself at least twice daily. W h e n
be comfortable with negative thoughts or feelings while Emily a t t e m p t e d to take the scale on a family vacation,
working toward valued goals. In essence, the client's ef- h e r m o t h e r r e m o v e d the scale from the h o m e , con-
fort to control the u n c o n t r o l l a b l e is r e d i r e c t e d o n t o con- c e r n e d a b o u t Emily's obsession with h e r weight. H e r
trollable areas of life. Many ACT interventions are meta- swimming coach also b e c a m e c o n c e r n e d with Emily's fa-
phorical, which involves the imaginative, b u t n o t literal, tigue d u r i n g practices. She was r e q u i r e d to k e e p a f o o d
application o f an ACT-relevant t h e m e to an object or diary a n d r e p o r t e d m i s r e p r e s e n t i n g h e r f o o d intake to
action. A s u m m a r y of ACT is p r o v i d e d in Table 1 (for a please h e r coach.
m o r e c o m p l e t e description, see Hayes et al., 1999). At intake a n d follow-up assessments, Emily c o m p l e t e d
A l t h o u g h a large-scale clinical trial evaluating the ef- the EDI-2, a 91-item self-report measure of symptoms as-
fectiveness o f ACT is u n d e r way, there are few p u b l i s h e d sociated with a n o r e x i a nervosa a n d b u l i m i a nervosa. It
o u t c o m e data on ACT. Hayes et al. (1999) suggest that consists o f eight standardized a n d three provisional sub-
ACT is likely to be effective for disorders involving exces- scales that assess behaviors a n d attitudes a b o u t eating,
sive experiential avoidance such as m o o d , anxiety, a n d weight, a n d shape, as well as m o r e general constructs a n d
personality disorders as well as chronic pain a n d relation- traits relevant to eating disorders. As shown in Table 2, at
ship problems. ACT has n o t b e e n specifically a p p l i e d to intake, Emily's scores on drive for thinness, ineffective-
the t r e a t m e n t of eating disorders such as a n o r e x i a ner- ness, a n d body dissatisfaction scales were in the anorexic,
vosa. O n e p u r p o s e of the p r e s e n t case example, there- restricting type, range. At termination, scores on the
fore, is to highlight how ACT c o m p o n e n t s can be incor- drive for thinness a n d ineffectiveness scales d r o p p e d to
p o r a t e d into a t r e a t m e n t plan for anorexia. A l t h o u g h the nonclinical range, a l t h o u g h b o d y dissatisfaction re-
o t h e r cognitive-behavioral techniques a n d family involve- m a i n e d in the clinical range.
m e n t were essential features of treatment, this p a p e r will Weight was assessed at each session. Figure 1 shows
focus primarily on the ACT-based interventions. that Emily's weight fluctuated initially, b u t eventually sta-
bilized n e a r h e r goal of 54.4 kg a n d increased to 56.7 kg
at follow-up.
Case Illustration
Therapist Characteristics
ACT T r e a t m e n t S u m m a r y
T h e therapist was a master's-level clinical psychology
g r a d u a t e s t u d e n t (MH) supervised by a Ph.D.-level clini- T h e p r i m a r y reason for i n c o r p o r a t i n g ACT c o m p o -
cal psychologist (JS) who specializes in CBT a n d behav- nents in therapy sessions was to establish acceptance o f
234 Heffner et al.

Table 2 satisfied with her body. Indeed, Emily's at-

EDI-2 Score Results at Intake and Termination tempts to c o n t r o l h e r weight had resulted
Intake Termination in less perceived control over life events.
Emily was p e r m i t t e d to take the finger trap
Scale Raw S c o r e Percen tile Raw S c o r e Percentile h o m e to increase its f u n c t i o n as a discrimi-
Drive for thinness 17a 71 11 50 native stimulus for acceptance in h e r natu-
Bulimia 0 56 1 69 ral e n v i r o n m e n t .
Body dissatisfaction 30~ 94 30a 94
Ineffectiveness 17a 73 8 43 Chessboard Metaphor
Perfectionism 5 34 5 34 The concept of acceptance was intro-
Interpersonal distrust 2 28 ] 19
Interoceptive awareness 9 52 9 52 duced by the third session, a n d the chess-
Maturity fears 3 53 4 60 board m e t a p h o r was adapted from ACT to
demonstrate the importance of b e i n g an ob-
Note. Normative group is female anorexia, restricting type, patients. server (acceptance), n o t a reactor (avoid-
aIndicates score is in the clinical range.
ance), of negative thoughts. In this meta-
phor, the chess pieces are at war with o n e
weight-related cognitions a n d to redirect the client's another, while the board is merely an observer. The
drive for thinness onto healthiex, valued directions a n d board never loses, but the pieces are constantly b e i n g at-
goals. tacked a n d knocked off the board. Emily was f u n c t i o n i n g
as a chess piece by fighting off the "fat thoughts," a n d she
The Chinese Finger Trap was losing at the game. The therapist e n c o u r a g e d Emily
The finger trap consists of a tube of woven straw. Both to play the game in a new way by serving as the board a n d
index fingers can slide in, one finger at each end. After observing the fight rather than participating in it. The
insertion, if the fingers pull out, the tube catches a n d board can never lose, n o matter what the outcome may be.
tightens. The only way to escape is to push the fingers in,
then slide them out. T h e therapist n o t only presented the Thought Parade
m e t a p h o r verbally, but also allowed Emily to experience To further encourage observation of negative
the finger trap in session. Recent findings from our labo- thoughts, the t h o u g h t parade, described in the ACT
ratory (Heffner & Eifert, 2000) indicate that this behav- manual, was practiced in session. Emily was instructed to
ioral c o m p o n e n t may increase the metaphor's credibility close her eyes a n d visualize herself observing a parade
a n d efficacy. The finger trap demonstrates that attempts with marchers carrying placards representing the nega-
to control an u n c o n t r o l l a b l e event (e.g., body weight) are tive thoughts she was trying to avoid (e.g., ' T m a whale";
futile, whereas efforts to "push in" a n d accept one's body "My stomach is gross"). For homework, Emily recorded
are more beneficial. Emily a n d the therapist discussed weight-related thoughts, level of acceptance, a n d subse-
how Emily's control agenda (i.e., n o t eating) has b e e n q u e n t behaviors. The results of the homework d e m o n -
counterproductive as she is fatigued, hungry, a n d still n o t strated that increased acceptance of weight-related
thoughts led to less anorexic behavior, whereas unwilling-
ness to remain in contact with such thoughts led to in-
Therapy Follow-Up creased restriction.
57
Valued Directions Map
56 Figure 2 shows a concrete, visual map of valued direc-
tions. O n e road, representing anorexia, leads to a dead
55
end. The other roads, representing valued directions, are
i n t e r c o n n e c t e d a n d never ending. Emily specified her
.¢ 54
values on the ACT Values Assessment Worksheet, a n d the
53 therapist explained how eating would move her toward
o
those directions (e.g., eating would give her more energy
52 to succeed at swimming). This m a p was referred to fre-
quently t h r o u g h o u t therapy.
51 L

2 4 6 8 10 12 14 16 18
Bus Driver Metaphor
Session
The bus driver m e t a p h o r requires the patient to imag-
leisure I. Weight (kg) across therapy and follow-up sessions. ine b e i n g a bus driver with passengers, "fat thoughts,"
 Act and Anorexia
A SPIRITUALITY
R for loving animals, a n d b e i n g a g o o d swimmer, daughter,
E ©
~ ~o./w Aead~. © E EDUCATION
R
CITIZENSHIP
F I e daily, a n d the therapist reviewed the food p y r a m i d with
R LEISURE
i ©
E
N
D HEALTH
is [ @
FAMILY RELATIONS
~Dead End ® volve achieving perfection, b u t r a t h e r persevering toward
Figure 2. A concrete, visual map of valued directions that are
never ending and interconnected.
taunting h e r to c h a n g e directions a n d drive the bus down
the anorexic road. As the driver o f the bus, she n e e d e d to
c o n t i n u e in h e r valued direction without a t t e m p t i n g to
intervene with the passengers o r react to them. As h o m e -
work, Emily was asked to plot a bus on a g r a p h each day
to indicate which direction she was moving h e r bus. We
also asked Emily to k e e p a daily j o u r n a l a b o u t the direc-
tion she chose to move the bus for that day. T h e following
sample diary entry reflects Emily's new valued direction:
a focus on life goals that d o n o t involve losing weight.
Each day that I live, I want to be a day to give the
best of me. As o f now, I am still o c c u p i e d perfecting
my grades, my relationship with my friends, a n d so
on. I want to be r e m e m b e r e d as an excellent writer.
I, personally, strive to be the best in almost any area.
It's n o t a b o u t b e i n g Miss Goody-Two-Shoes o r a
teacher's pet, b u t it's a b o u t m a k i n g s o m e t h i n g o u t
o f my life so that I won't regret it when ! sway back
a n d forth in a rocking chair years from now. Give
the best o f yourself a n d you'll realize you've accom-
plished s o m e t h i n g to be strongly p r o u d of.
235
Funeral Meditation
Emily was asked to visualize h e r own funeral. She
i m a g i n e d a n d d e s c r i b e d what significant others were say-
ing at the funeral a n d how they were r e m e m b e r i n g h e r
friend, a n d writer. Afterward, Emily a n d the therapist dis-
cussed how she d i d n o t observe anyone r e m e m b e r i n g h e r
for b e i n g thin o r having a nice body. In the end, Emily's
weight will n o t matter, b u t h e r legacy will be left in the
lives she t o u c h e d a n d the causes she c o n t r i b u t e d to. At
this p o i n t in therapy, Emily asked what she n e e d e d to eat
her. Emily c o m m i t t e d to eating breakfast daily.
C o m m i t m e n t to V a l u e d D i r e c t i o n s
T h e r e m a i n d e r of the therapy sessions focused on
Emily's individualized directions a n d r e i n f o r c e m e n t for
h e r achievements toward h e r goals a n d values. F o r exam-
ple, Emily wanted to be a veterinarian a n d h a d b e e n help-
ing stray animals. T h e therapist p r e s e n t e d Emily with a
certificate to acknowledge this achievement. T h e thera-
pist continually e m p h a s i z e d that c o m m i t m e n t d i d n o t in-
a goal, despite setbacks o r mistakes.
D u r i n g the course o f treatment, anorexic symptoms
b e g a n to r e m i t within 10 sessions, a n d t r e a t m e n t gains
were m a i n t a i n e d at m o n t h l y follow-up sessions. Emily's
weight increased to a healthy level o f 56.7 kg at termina-
tion, h e r desire for thinness a n d feelings o f ineffective-
ness decreased, a n d h e r menstrual cycle r e t u r n e d . Emily
stated that, a l t h o u g h she initially d i d n o t want to a t t e n d
therapy sessions, she eventually realized the t r e a t m e n t
was beneficial. H e r parents were also satisfied with the
o u t c o m e o f the t r e a t m e n t p r o g r a m .
Discussion
ACT techniques were i n c o r p o r a t e d to treat avoidance
associated with a n o r e x i a nervosa by increasing accep-
tance o f weight-related cognitions a n d r e d i r e c t i n g the cli-
ent's desire for thinness o n t o healthier, valued directions
a n d goals. Rather than a t t e m p t i n g to control a n d r e d u c e
h e r weight, we e n c o u r a g e d the client to accept h e r b o d y
by e n g a g i n g in several exercises a d a p t e d from the ACT
m a n u a l (e.g., t h o u g h t p a r a d e , chessboard m e t a p h o r ) .
Emily t h e n b e g a n to identify valued goals, a n d the thera-
pist r e i n f o r c e d h e r efforts to achieve them. This treat-
m e n t p l a n resulted in the remission o f most anorexic
symptoms. T h e only r e m a i n i n g symptom was Emily's
body dissatisfaction, as m e a s u r e d by the EDI-2. However,
it is i m p o r t a n t to note that the t r e a t m e n t goal was n o t to
eliminate b o d y dissatisfaction, b u t to accept thoughts a n d
feelings o f b o d y dissatisfaction a n d refocus h e r e n e r g y
236 Heffner et al.
toward a c h i e v i n g c h o s e n goals. Thus, a l t h o u g h Emily was
n o t satisfied with h e r body, she was able to r e s u m e a
h e a l t h y lifestyle in spite o f w e i g h t - r e l a t e d t h o u g h t s a n d
feelings.
It is i m p o r t a n t to n o t e that several aspects o f t r e a t m e n t
m a y have i n c r e a s e d the effectiveness o f A C T t e c h n i q u e s
for this i n d i v i d u a l case. First, A C T m e t a p h o r s , such as the
f i n g e r trap a n d c h e s s b o a r d , w e r e d e l i v e r e d in an experi-
ential fashion. R a t h e r t h a n simply telling the p a t i e n t
a b o u t t h e m e t a p h o r , we e x p o s e d the c l i e n t to t h e visual,
auditory, a n d tactile c o m p o n e n t s o f the m e t a p h o r by hav-
i n g h e r m a n i p u l a t e an actual f i n g e r trap, for e x a m p l e .
S e c o n d , the v a l u e d d i r e c t i o n s p h a s e o f A C T i n c l u d e d a
m a p , w h i c h s u p p l e m e n t e d the A C T v a l u e d - d i r e c t i o n s
component. The map provided a concrete explanation
a n d visualization to s u p p l e m e n t Emily's list o f goals. In-
c o r p o r a t i n g such c o n c r e t e m e a n s may be particularly im-
p o r t a n t in t h e t r e a t m e n t o f c h i l d r e n a n d adolescents,
w h o have e v e n m o r e p r o b l e m s f o l l o w i n g abstract descrip-
tions t h a n adults. T h e r e f o r e , we also u s e d an actual m a p
to c o m p l e m e n t the bus driver m e t a p h o r .
T h e successful results o f this t r e a t m e n t d o n o t attest to
the efficacy o f A C T t e c h n i q u e s a l o n e b e c a u s e we c o m -
b i n e d these t e c h n i q u e s with p a r e n t a l s u p p o r t , r a p p o r t ,
a n d o t h e r s t a n d a r d c o g n i t i v e - b e h a v i o r a l t e c h n i q u e s . This
case study m e r e l y p r o v i d e s an e x a m p l e o f h o w A C T tech-
n i q u e s can be i n c o r p o r a t e d i n t o a b e h a v i o r a l t r e a t m e n t
for this serious p r o b l e m . It is i m p o r t a n t to n o t e that this
p a r t i c u l a r c l i e n t was h i g h f u n c t i o n i n g a n d in the early
stages o f a n o r e x i a . It is n o t k n o w n w h e t h e r A C T - b a s e d
i n t e r v e n t i o n s w o u l d be as efficacious with c h r o n i c o r in-
p a t i e n t anorexics. Finally, we k n o w little a b o u t the use o f
A C T with c h i l d r e n a n d adolescents, b u t t h e therapy's use
o f m e t a p h o r s (as o p p o s e d to d i r e c t c o m m a n d s / r u l e s )
a n d c o n c r e t e e x p l a n a t i o n s a p p e a r to be particularly well
suited for this p o p u l a t i o n . T h e v a l u e d d i r e c t i o n s p o r t i o n
o f A C T is especially r e l e v a n t to c h i l d r e n a n d a d o l e s c e n t s
w h o s e goals have yet to be m o l d e d .
F u r t h e r r e s e a r c h a n d case studies e x p l o r i n g the effects
o f A C T o n a n o r e x i a c o u l d h e l p d e v e l o p m o r e effective
t r e a t m e n t s for this potentially l i f e - t h r e a t e n i n g , difficult-
to-treat disorder. A C T ' s u n i q u e focus o n u n d e r m i n i n g in-
effective c o n t r o l strategies a n d e x p e r i e n t i a l a v o i d a n c e
m a k e s it a t h e o r e t i c a l l y ideal t r e a t m e n t for a n o r e x i a . Cli-
ents l e a r n to a c c e p t r a t h e r t h a n fight t h e i r n e g a t i v e feel-
ings o f b o d y dissatisfaction while s i m u l t a n e o u s l y w o r k i n g
toward valued, h e a l t h y life goals.
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We gratefully acknowledge the support of our clinical team members
Lesley Koven, Vicki Lumley, and Brandie Taylor.
Address correspondence to Michelle Heffnet; West Virginia
University, Department of Psychology, PO Box 6040, Morgantown, WV
26506-6040; e-mail: mheffner@wvu.edu.
Received: August 18, 2000
Accepted: June 28, 2001