Heffner, Michelle [et al.] – Acceptance and Commitment Therapy in the Treatment of an Adolescent Female With Anorexia Nervosa: A Case Example. Cognitive and Behavioral Practice, 9:3 (2002) 232-236.

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Cognitive and Behavioral Practice 9, 232-236, 2002
1077-7229/02/232-236$1.00/0
Copyright © 2002 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

COGNITIVE BEHAVIORAL CASE CONFERENCE
Acceptance and Commitment Therapy in the Treatment of an Adolescent Female With Anorexia Nervosa: A Case Example
Michelle Heffner, Jeannie Sperry, Georg H. Eifert, and Michael Detweiler, West Virginia University
Acceptance and Commitment Therapy (ACT) is a cognitive-behavioral treatment that targets ineffective control strategies and experiential avoidance — the unwillingness to accept negative thoughts, feelings, and emotions. Although ACT has been suggested as an effective treatment for panic, substance use, pain, and mood disorders, there are no published reports on the use of ACT for treating adolescent disorders such as anorexia nervosa. This case summarizes the successful adoption of ACT techniques in the treatment of a 15-year-old female with anorexia nervosa. It also shows how ACT techniques can be successfully combined with, and set the stage for, more standard cognitive-behavioral interventions.
	ANOREXIA NERVOSA is a serious psychological condition in which an individual fails to maintain a minimally normal body weight, has an intense fear of weight gain, and perceives body weight or shape inaccurately. Adolescent females are most at risk for developing the disorder, with onset as early as age 14. Early detection and intervention are essential, as the disorder becomes more difficult to treat as it progresses (Bulik, 1998). Anorexia can lead to several serious health consequences, such as kidney damage, cardiovascular problems, and osteoporosis. In severe cases, death can result from multiple organ failure or electrolyte imbalance. The aggregate mortality rate for anorexia has been estimated at .56% per year, which is 12 times greater than the annual death rate due to all causes of death for 15- to 24-year-old females in the general population (Sullivan, 1995).
	In spite of these potential life-threatening consequences of anorexia, the development of effective cognitive-behavior therapy (CBT) for anorexia is still ongoing (Wilson, 1999). Although several well-established CBT manuals and empirically validated treatments exist for treating bulimia nervosa and binge eating (Agras & Apple, 1997; Fairburn, Marcus, & Wilson, 1993; Thackwray, Smith, Bodfish, & Meyers, 1993; Willley, Agras, Telch, & Rossiter, 1993), these particular treatments are not suitable for anorexia. Despite the absence of any published CBT manuals for treating anorexia, interventions have typically employed some form of self-monitoring and contingency management. Self-monitoring requires the participant to detail eating behaviors and the contexts in which they occur to index treatment progress and guide contingency planning (Wilson & Vitousek, 1999). Based on this information, a contingency plan can be set up to provide access to reinforcers after eating and to remove contexts or events that trigger self-starvation.
	In spite of these efforts, anorexia remains a difficult disorder to treat. One recently-developed CBT program, Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), may be useful in the treatment of anorexia because this cognitive-behavioral treatment targets core problems in anorexia: ineffective control strategies and the unwillingness to remain in contact with negative emotions or thoughts (experiential avoidance). One component of ACT is to examine control strategies as problems, not solutions. This fits well with a recent cognitive-behavioral theory of anorexia, which proposes that a problematic need for control maintains this eating disorder (Fairburn, Shafran, & Cooper, 1999) and that dietary restriction is reinforced by the sense of being in control, particularly if the individual has failed at controlling other areas of life. Another feature of anorexia is the avoidance of thoughts or feelings related to weight and body image. In a recent study examining the relation between cognitive avoidance and disordered eating, college women who scored high on two Eating Disorders Inventory (EDI-2; Garner, 1991) subscales took longer to process threat-related words (for example, fail) than women with lower EDI-2 scores (Meyer, Waller, & Watson, 2000). This suggests that experiential avoidance may play a role in eating disorders, and food restriction could be the anorexic's attempt to avoid or reduce negative weight or body image thoughts.
	An ACT approach to treatment makes no attempt to change or eliminate avoidance agendas, but instead encourages acceptance of bothersome thoughts and feelings. An ACT treatment plan seeks to undermine ineffective control and avoidance strategies by helping the client identify valued life directions and providing the client with support to achieve them. Thus, negative emotions and thoughts are not obstacles but an expected part of goal-directed behavior.

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Nota de revisor: a seguir apresenta-se uma tabela constituída por duas colunas e 7 linhas cujo título é: Table 1 Overview of Core ACT Treatment Strategies.
Component/Strategy	Coal/Purpose	
1. Creative hopelessness	Client views avoidant solutions as problems by employing paradox and metaphors to disrupt ongoing avoidance repertoires.	
2. Control is the problem	Client explores ways in which avoidance behavior inhibits life functioning.	
3. Self as context	Client discriminates between oneself and one's problem behavior; provides context in which acceptance is possible and avoidance is unnecessary.	
4. Choosing a valued direction	Client actively determines valued life directions.	
5. Letting go of struggle/ embracing symptoms	Client experiences symptoms without avoidance; facilitates contact with direct contingencies by encouraging client to deliberately experience avoided thoughts and feelings.	
6. Behavior change commitment	Client progresses toward committed, valued directions.	
In this way, clients learn to recognize and be comfortable with negative thoughts or feelings while working toward valued goals. In essence, the client's effort to control the uncontrollable is redirected onto controllable areas of life. Many ACT interventions are metaphorical, which involves the imaginative, but not literal, application of an ACT-relevant theme to an object or action. A summary of ACT is provided in Table 1 (for a more complete description, see Hayes el al., 1999).
	Although a large-scale clinical trial evaluating the effectiveness of ACT is under way, there are few published outcome data on ACT. Hayes et al. (1999) suggest that ACT is likely to be effective for disorders involving excessive experiential avoidance such as mood, anxiety, and personality disorders as well as chronic pain and relationship problems. ACT has not been specifically applied to the treatment of eating disorders such as anorexia nervosa. One purpose of the present case example, therefore, is to highlight how ACT components can be incorporated into a treatment plan for anorexia. Although other cognitive-behavioral techniques and family involvement were essential features of treatment, this paper will focus primarily on the ACT-based interventions.
Case Illustration
Therapist Characteristics
	The therapist was a master's-level clinical psychology graduate student (MH) supervised by a Ph.D.-level clinical psychologist (JS) who specializes in CBT and behavioral medicine. Weekly outpatient treatment followed by monthly checkups were conducted from November 1999 to July 2000. A total of 18 sessions were conducted at the Quin Curtis Center (QCC), located in the Department of Psychology at West Virginia University. The QCC provides general mental health services and treatment by graduate student therapists supervised by licensed psychologists.
Patient Characteristics: History and Assessment
	Emily, a 15-year-old Caucasian female, was brought to treatment by her mother and diagnosed with anorexia nervosa, restricting type. She resided in a middle-class family with both biological parents and her 13-year-old brother. Emily's level of functioning was high, and she had no prior history of psychopathology. At the time of the intake, Emily's height was 1.7 metres and her weight was 51 kilograms (Body Mass Index <18). Her menstrual cycle had been absent for 3 months.
	Approximately 11 months prior to her presentation at the clinic, Emily began to notice the "thinness" of her female classmates. She became dissatisfied with her body and began to diet and occasionally refused to eat for an entire day. She developed a morbid fear of gaining weight and weighed herself at least twice daily. When Emily attempted to take the scale on a family vacation, her mother removed the scale from the home, concerned about Emily's obsession with her weight. Her swimming coach also became concerned with Emily's fatigue during practices. She was required to keep a food diary and reported misrepresenting her food intake to please her coach.
	At intake and follow-up assessments, Emily completed the EDI-2, a 91-item self-report measure of symptoms associated with anorexia nervosa and bulimia nervosa. It consists of eight standardized and three provisional sub-scales that assess behaviors and attitudes about eating, weight, and shape, as well as more general constructs and traits relevant to eating disorders. As shown in Table 2, at intake, Emily's scores on drive for thinness, ineffectiveness, and body dissatisfaction scales were in the anorexic, restricting type, range. At termination, scores on the drive for thinness and ineffectiveness scales dropped to the nonclinical range, although body dissatisfaction remained in the clinical range.
	Weight was assessed at each session. Figure 1 shows that Emily's weight fluctuated initially, but eventually stabilized near her goal of 54.4 kilograms and increased to 56.7 kilograms at follow-up.
ACT Treatment Summary
	The primary reason for incorporating ACT components in therapy sessions was to establish acceptance of weight-related cognitions and to redirect the client's drive for thinness onto healthier, valued directions and goals.

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Nota de revisor: a seguir apresenta-se uma tabela constituída por 5 colunas e 10 linhas cujo título é: Table 2 EDI-2 Score Results at Intake and Termination. Esta tabela é acompanhada pela legenda: a - Indicates score is in the clinical range e pela nota: Normative group is female anorexia, restricting type, patients.
[sem informação]	Intake	Termination	
Scale	Raw Score	Percentile	Raw Score	Percentile	
Drive for thinness	17 a	71	11	50	
Bulimia	0	56	1	69	
Body dissatisfaction	30 a	94	30 a	94	
Ineffectiveness	17 a	73	8	43	
Perfectionism	5	34	5	34	
Interpersonal distrust	2	28	1	19	
Interoceptive awareness	9	52	9	52	
Maturity fears	3	53	4	60	
The Chinese Finger Trap
	The finger trap consists of a tube of woven straw. Both index fingers can slide in, one finger at each end. After insertion, if the fingers pull out, the tube catches and tightens. The only way to escape is to push the fingers in, then slide them out. The therapist not only presented the metaphor verbally, but also allowed Emily to experience the finger trap in session. Recent findings from our laboratory (Heffner & Eifert, 2000) indicate that this behavioral component may increase the metaphor's credibility and efficacy. The finger trap demonstrates that attempts to control an uncontrollable event (e.g., body weight) are futile, whereas efforts to "push in" and accept one's body-are more beneficial. Emily and the therapist discussed how Emily's control agenda (that is, not eating) has been counterproductive as she is fatigued, hungry, and still not satisfied with her body. Indeed, Emily's attempts to control her weight had resulted in less perceived control over life events. Emily was permitted to Lake the finger trap home to increase its function as a discriminative stimulus for acceptance in her natural environment.

Nota de revisor: a seguir apresenta-se a imagem de um gráfico cujo título é: Figure 1. Weight (kg) across therapy and follow-up sessions.

Chessboard Metaphor
	The concept of acceptance was introduced by the third session, and the chessboard metaphor was adapted from ACT to demonstrate the importance of being an observer (acceptance), not a reactor (avoidance), of negative thoughts. In this metaphor, the chess pieces are at war with one another, while the board is merely an observer. The board never loses, but the pieces are constantly being attacked and knocked off the board. Emily was functioning as a chess piece by fighting off the "fat thoughts," and she was losing at the game. The therapist encouraged Emily to play the game in a new way by serving as the board and observing the fight rather than participating in it. The board can never lose, no matter what the outcome may be.
Thought Parade
	To further encourage observation of negative thoughts, the thought parade, described in the ACT manual, was practiced in session. Emily was instructed to close her eyes and visualize herself observing a parade with marchers carrying placards representing the negative thoughts she was trying to avoid (for example, "I'm a whale"; "My stomach is gross"). For homework, Emily recorded weight-related thoughts, level of acceptance, and subsequent behaviors. The results of the homework demonstrated that increased acceptance of weight-related thoughts led to less anorexic behavior, whereas unwillingness to remain in contact with such thoughts led to increased restriction.
Valued Directions Map
	Figure 2 shows a concrete, visual map of valued directions. One road, representing anorexia, leads to a dead end. The other roads, representing valued directions, are interconnected and never ending. Emily specified her values on the ACT Values Assessment Worksheet, and die therapist explained how eating would move her toward those directions (for example, eating would give her more energy to succeed at swimming). This map was referred to frequently throughout therapy.

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Nota de revisor: a seguir apresenta-se uma imagem cujo título é: Figure 2. A concrete, visual map of valued directions that are never ending and interconnected.

Bus Driver Metaphor
	The bus driver metaphor requires the patient to imagine being a bus driver with passengers, "fat thoughts", taunting her to change directions and drive the bus down the anorexic road. As the driver of the bus, she needed to continue in her valued direction without attempting to intervene with the passengers or react to them. As homework, Emily was asked to plot a bus on a graph each day to indicate which direction she was moving her bus. We also asked Emily to keep a daily journal about the direction she chose to move the bus for that day. The following sample diary entry reflects Emily's new valued direction: a focus on life goals that do not involve losing weight.
	Each day that I live, I want to be a day to give the best of me. As of now, I am still occupied perfecting my grades, my relationship with my friends, and so on. I want to be remembered as an excellent writer. I, personally, strive to be the best in almost any area. It's not about being Miss Goody-Two-Shoes or a teacher's pet, but it's about making something out of my life so that I won't regret it when I sway back and forth in a rocking chair years from now. Give the best of yourself and you'll realize you've accomplished something to be strongly proud of.
Funeral Meditation
	Emily was asked to visualize her own funeral. She imagined and described what significant others were saying at the funeral and how they were remembering her for loving animals, and being a good swimmer, daughter, friend, and writer. Afterward, Emily and the therapist discussed how she did not observe anyone remembering her for being thin or having a nice body. In the end, Emily's weight will not matter, but her legacy will be left in the lives she touched and the causes she contributed to. At this point in therapy, Emily asked what she needed to eat daily, and the therapist reviewed the food pyramid with her. Emily committed to eating breakfast daily.
Commitment to Valued Directions
	The remainder of the therapy sessions focused on Emily's individualized directions and reinforcement for her achievements toward her goals and values. For example, Emily wanted to be a veterinarian and had been helping stray animals. The therapist presented Emily with a certificate to acknowledge this achievement. The therapist continually emphasized that commitment did not involve achieving perfection, but rather persevering toward a goal, despite setbacks or mistakes.
	During the course of treatment, anorexic symptoms began to remit within 10 sessions, and treatment gains were maintained at monthly follow-up sessions. Emily's weight increased to a healthy level of 56.7 kilograms at termination, her desire for thinness and feelings of ineffectiveness decreased, and her menstrual cycle returned. Emily stated that, although she initially did not want to attend therapy sessions, she eventually realized the treatment was beneficial. Her parents were also satisfied with the outcome of the treatment program.
Discussion
	ACT techniques were incorporated to treat avoidance associated with anorexia nervosa by increasing acceptance of weight-related cognitions and redirecting the client's desire for thinness onto healthier, valued directions and goals. Rather than attempting to control and reduce her weight, we encouraged the client to accept her body by engaging in several exercises adapted from the ACT manual (for example, thought parade, chessboard metaphor). Emily then began to identify valued goals, and the therapist reinforced her efforts to achieve them. This treatment plan resulted in the remission of most anorexic symptoms. The only remaining symptom was Emily's body dissatisfaction, as measured by the EDI-2. However, it is important to note that the treatment goal was not to eliminate body dissatisfaction, but to accept thoughts and feelings of body dissatisfaction and refocus her energy toward achieving chosen goals.

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Thus, although Emily was not satisfied with her body, she was able to resume a healthy lifestyle in spite of weight-related thoughts and feelings.
	It is important to note that several aspects of treatment may have increased the effectiveness of ACT techniques for this individual case. First, ACT metaphors, such as the finger trap and chessboard, were delivered in an experiential fashion. Rather than simply telling the patient about the metaphor, we exposed the client to the visual, auditory, and tactile components of the metaphor by having her manipulate an actual finger trap, for example. Second, the valued directions phase of ACT included a map, which supplemented the ACT valued-directions component. The map provided a concrete explanation and visualization to supplement Emily's list of goals. Incorporating such concrete means may be particularly important in the treatment of children and adolescents, who have even more problems following abstract descriptions than adults. Therefore, we also used an actual map to complement the bus driver metaphor.
	The successful results of this treatment do not attest to the efficacy of ACT techniques alone because we combined these techniques with parental support, rapport, and other standard cognitive-behavioral techniques. This case study merely provides an example of how ACT techniques can be incorporated into a behavioral treatment for this serious problem. It is important to note that this particular client was high functioning and in the early stages of anorexia. It is not known whether ACT-based interventions would be as efficacious with chronic or inpatient anorexics. Finally, we know little about the use of ACT with children and adolescents, but the therapy's use of metaphors (as opposed to direct commands/rules) and concrete explanations appear to be particularly well suited for this population. The valued directions portion of ACT is especially relevant to children and adolescents whose goals have yet to be molded.
	Further research and case studies exploring the effects of ACT on anorexia could help develop more effective treatments for this potentially life-threatening, difficult-to-treat disorder. ACT's unique focus on undermining ineffective control strategies and experiential avoidance makes it a theoretically ideal treatment for anorexia. Clients learn to accept rather than fight their negative feelings of body dissatisfaction while simultaneously working toward valued, healthy life goals.
References
Agras, W. S., & Apple, R. F. (1997). Overcoming eating disorders: A cognitive-behavioral treatment for bulimia nervosa and binge-eating disorder. San Antonio, TX: Graywind Publications.
Bulik, C. M. (1998). Women and disordered eating. In S. E. Romans (Ed.), Folding back the shadows: A perspective on women's mental health. Dunedin, New Zealand: University of Otago Press.
Fairburn, C. G., Marcus, M. D., & Wilson, T. G. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment. New York: The Guilford Press.
Fairburn, G. G., Shafran, R., & Cooper, Z. (1999). A cognitive-behavioural theory of anorexia nervosa. Behaviour Research and Therapy, 37, 1-13.
Garner, D. M. (1991). Eating Disorders Inventory—2: Professional manual. Odessa, FL: Psychological Assessment Resources.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: The Guilford Press.
Hayes, S. C. & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the verbal support for experiential avoidance. The Behavior Analyst, 17, 289-303.
Heffner, M., & Eifert, G. H. (2000). The effects of acceptance versus control contexts on avoidance of panic-related symptoms. Manuscript submitted for publication.
Meyer, C., Waller, G., & Watson, D. (2000). Cognitive avoidance and bulimic psychopathology: The relevance of temporal factors in a nonclinical population. International Journal of Eating Disorders, 27, 405-410.
Sullivan, P. F. (1995). Mortality in anorexia nervosa. American Journal of Psychiatry. 152, 1073-1074.
Thackwray, D. E., Smith, M. C., Bodfish, J. W., & Meyers, A. W. (1993). The comparison of behavioral and cognitive-behavioral interventions for bulimia nervosa, Journal of Consulting and Clinical Psychology, 61, 639-645.
Wilfley, D. E., Agras, W. S., Telch, C. F., & Rossiter, E. M. (1993). Group cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic individual: A controlled comparison. Journal of Consulting and Clinical Psychology, 61, 296-305.
Wilson, G. T. (1999). Cognitive behavior therapy for eating disorders: Progress and problems. Behaviour Research and Therapy, 37 (Suppl. 1), S79-S95.
Wilson, G. T., & Vitousek, K. M. (1999). Self-monitoring in the assessment of eating disorders. Psychological Assessment, 11, 480-489.
We gratefully acknowledge the support of our clinical team members Lesley Koven, Vicki Lumley, and Brandie Taylor.

Address correspondence to Michelle Heffner, 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