Acceptance Commitment Therapy in Eating Disorders

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By: Melissa Gerson, LCSW

Imagine this: You walk into a social gathering to find yourself among a group of people you don’t know. Immediately thoughts begin flowing into your mind: “I don’t know anyone here!” “Who should I talk to?” “If I am standing here talking to nobody, people will think I am a loser” “What if I go up to someone and they don’t want to speak with me.” “I look so awkward right now” “This shouldn’t be so hard for me.” The next thing you experience is the your heart pounding so loud you are convinced others can hear it, beads of sweat dripping down your forehead and an extreme desire to flee the situation.

In this scenario, the attachment to these thoughts and worries led to an emotion we may know all too well: anxiety. In our work with eating disorders, we find that anxiety is often a trigger for destructive food behaviors: restriction, binging, purging or some combination.

From the perspective of ACT, also known as Acceptance and Commitment Therapy, the intensity of anxiety experienced in this aforementioned scenario arises from a process known as cognitive fusion.

Cognitive fusion is a term coined by Russell Harris, the founder of ACT. It describes a process in which we are bound to and inseparable from our thoughts. You can say that we are welded or bonded to them so strongly that we begin to see them as more than just thoughts, and rather as absolute truths or facts.

Rather than noticing or observing, “I look so awkward right now” as a thought, in a state of fusion, we experience it as a fact about reality: “I look so awkward right now and therefore I am so awkward right now.” We become stuck to these thoughts, which fuels their power over our behavior. In other words, these thoughts may motivate us to avoid engagement in conversation with others, leave a social gathering or perhaps engage in maladaptive behaviors to reduce the unwanted negative emotion that ensues, all of which causes us to lose contact with reality and our experience with the present moment. Rather than creating contact with the world of direct experience, we become lost in the world of language.

So how can we recognize when we are in a state of fusion? According to ACT, we can watch out for fusion in 6 areas:

1. Rules

Are there any implicit rules that you find you hold for yourself about work, relationships or about life in general? Do you ever notice yourself saying words like should, can’t, must, have to, ought?

2. Reasons

Do you find yourself generating rationales about why change is unattainable for you specifically? Fusion to these thoughts can get in the way of creating movement necessary for recovery. It reduces self-efficacy and prevents us from making the change we are capable of making.

3. Judgments

Although judging in certain circumstances can be important and even useful, many judgments can be unhelpful and harmful. Fusion to judgments about ourselves and others including, “I am ugly” or “I am an addict” can be detrimental and preclude us from developing meaningful lives. These judgments of evaluation enhance our suffering by disconnecting us from facts about ourselves and the world around us.

4. Past

Although the past has already happened, you may find yourself stuck to certain moments in your past. Fusion to these thoughts detaches us from the present moment and the world of direct experience. We may lose touch with things right in front of our eyes that may bring us joy and pleasure.

5. Future

Although the future has not happened yet, do you find yourself worrying about things that might happen? Fusion to thoughts about the future pulls us away from being effective in the present moment and may exacerbate high levels of anxiety.

6. Self

Are you attaching to a certain description of yourself? These can include thoughts like “I am depressed” or “I am sick.” Sticking to these thoughts make them rigid and inflexible and therefore, can prevent us from becoming the people we want to be living the lives we want to live.

The good news is ACT has a solution. From the ACT perspective, the way to reduce psychological suffering is to change our relationship to distressing thoughts. This can be achieved through a process called Defusion. Through defusion, we learn to create distance between ourselves and our thoughts, which help us see them for what they are: words, images and pictures. This is not to say that these distressing thoughts will not enter our mind, rather defusion teaches us that when they do, they do not have to dictate our behavior. Through this separation, we can begin observing thoughts as statements that may or may not be true and that can enter as well as exit our minds.

Harris, R. (2009). ACT made simple. Oakland, CA: New Harbinger Publications, Inc.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

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