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  • 1. Using Mindfulness & Acceptance and Commitment Therapy (ACT) for Treating BED Joyce D. Nash, Ph.D. [email_address] www.drjoycenash.com @drjnash
  • 2. My Book & Blog
    • “Lose Weight, Live Healthy: A Complete Guide to Designing Your Own Weight Loss Program”
    • www.loseweightlivehealthyguide.com
    • www.loseweightlivehealthyguide.com/blog/
    • For a copy of this powerpoint presentation, go to:
    • www.loseweightlivehealthyguide.com/Renfrew_2011_ACT_BED_Nash
  • 3. Agenda
    • How ACT differs from Cognitive Therapy
    • Mindfulness
    • BED essentials
    • Introduction of an actual BED client
    • Basics of ACT
    • Videos
    • Obesity-related research
  • 4. ACT is like a New Concept Car
    • ACT has both theoretical and empirical support
    • Based on Rational Frame Theory (RFT)
    • Developed by Steven Hayes, Ph.D., at University of Nevada at Reno, and his associates
  • 5. How ACT Differs from Other CBT Approaches
    • Does not strive to change negatively perceived thoughts and feelings, but rather emphasizes acceptance of these private events
    • Does not dispute evidence for thoughts
    • Is context -focused (not content-focused)
    • Is not symptom-focused
  • 6. What ACT Does In Session
    • Uses experiential exercises in session
    • Makes extensive use of metaphor and paradox
    • Targets experiential avoidance and cognitive fusion
  • 7. Acceptance and Commitment Therapy (ACT)
    • A – Accept your thoughts, feelings, memories, and other private events as they occur moment to moment, without judgment
    • C – Clarify and connect with personally-defined values that give direction to your life, and set goals that support these values
    • T – Take effective action in accordance with your goals and values
  • 8. Aim of ACT
    • To help us create a rich, full, and meaningful life, while accepting the pain that life inevitably brings
  • 9. Sources of Pain and Discomfort
    • Clean Discomfort
    • Dirty Discomfort
  • 10. ACT and Mindfulness
    • ACT is not just mindfulness
    • ACT uses mindfulness as a means of accessing the observing self in the present moment
    • The observing self has no words but the thinking self is chattering continuously
  • 11. What is Mindfulness?
    • A mental state of awareness, focus, curiosity, openness, and receptiveness that allows you to engage fully in your here-and-now experience without judgment or referring to the past or future
  • 12.  
  • 13. Essentials of BED Diagnostic Criteria
    • Recurrent episodes
    • Larger than normal quantities of food
    • Feeling out of control
    • No regular use of compensatory behaviors
  • 14. Agenda of Control
    • Lack of control implies the need for more control
    • Control usually works in the external world
    • Doesn’t work well for thoughts and emotions
    • Binge is an attempt to stop thinking and feeling, that is, it is an experiential avoidance strategy
  • 15. Introducing Tina
    • Presenting complaints
    • History
    • Eating triggers
      • Family dynamics
      • Emotions
      • Unstructured time
      • Feeling of not fitting in
      • Social situations
      • Hunger, fatigue
  • 16. Triggers for Binges and Overeating
    • Negative emotions (emotional eating)
    • Positive social experiences
    • Low distress tolerance
    • Restrictive eating/dieting
    • Unstructured time/transition times
    • Readily available, high-energy, palatable food (food cues in the environment)
    • Evolutionary motivational system to ensure survival
  • 17.  
  • 18. Mindful Questions To Ask
    • What is triggering me to eat this food right now? (i.e., thoughts, feelings, cues)
    • What are my options other than eating? (i.e., what do I really need to do now?)
    • Is eating this food in line with my values and the option I want to choose at this time?
  • 19. Core Messages of ACT
    • Accept that you have at best limited control over your internal experiences, i.e., thoughts, emotions, memories, and internal experiences
    • Commit to taking actions that enrich your life because they are based on your values
  • 20. ACT and Values
    • Values are statements about
      • What you want to be doing with your life
      • What you want to stand for
      • How you want to behave on an ongoing basis
    • Values clarify what gives your life a sense of meaning or purpose
    • Values are chosen life directions
  • 21. Processes that Keep Us Stuck
    • Cognitive Fusion
      • You become fused with, melded with, and inseparable from your thoughts
      • Thoughts dominate behavior
      • Leads to unworkability
    • Experiential Avoidance
      • Trying to avoid, get rid of, suppress, or escape from unwanted thoughts, feelings, memories, fears
  • 22. Processes That Work
    • Defusion
      • Wherein thoughts, feelings, and urges come to be experienced from a psychological distance, i.e., the observing self
      • Being able to have a thought, feeling, craving, or urge without trying to suppress, believe or act on it
    • Acceptance
      • Learning to tolerate or be willing to have aversive internal experiences in the service of goal-related behavior
      • Alternative to control strategies
  • 23. Choosing Based on Values
    • Some ideas are worth considering
    • Ask yourself, “Does this contemplated action move me toward something I value?”
    • A good thing overdone undermines the value of health and well-being
  • 24.  
  • 25.  
  • 26. Definition of Psychological Flexibility
    • An individual’s ability to connect with the present moment fully, as a conscious human being, and to change or persist in behavior that is in line with identified values
  • 27. ACT in a Nutshell
    • Present focused
    • Experiential/metaphor
    • Between session work
    • Applicable to a variety of problems
  • 28. Some Obesity-related Research
    • Lillis, J., Hayes, S. C., Bunting, K., & Masauda, A. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37 :58-69.
    • Tapper, K., Chaw, C., Ilsley, J., Hill, A. J., Bond, F. W., Moore, L. (2009). Exploratory randomized controlled trial of a mindfulness-based weight loss intervention for women. Appetite, 52 :396-404.
    • Forman, E. M., Hoffman, K. L., McGrath, K. B., Herbert, J. D., Brandsman, L. L., Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: an analog study. Behavior Research and Therapy, 45 :2372-2386.
  • 29. More Obesity-Related Research
    • Lillis, J., Hayes, S. C., & Levin, M. E. (2011). Binge eating and weight control: the role of experiential avoidance. Behavior Modification, 35 :252-264.
    • Forman, E. M., Butryn, M. L., Hoffman, K. L., & Herbert, J. D. (2009). An open trial of an acceptance-based behavioral intervention for weight loss. Cognitive and Behavioral Practice, 16 :223-235.
    • Lillis, J., Levin, M. E., & Hayes, S. C. (2011). Exploring the relationship between body mass index and health-related quality of life: A pilot study of the impact of weight self-stigma and experiential avoidance. Journal of Health Psychology, 16(5) :722-727.
    • Weineland, S., Arvidsson, D., Kakoulidis, T, & Dahl, J. (2011). Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Obesity Research and Clinical Practice, e-l to e-10 . Published online 18 May 2011.
  • 30. Lillis, J., et al. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37 :58-69.
    • N = 84
    • Groups
      • Intervention
        • 1-day, 6-hour, mindfulness and acceptance-based workshop targeting obesity-related stigma and psychological distress (N = 43) (BMI = 33.59)
      • Wait list control
        • (N = 44) (BMI = 32.5)
  • 31. Lillis et al
    • Participant requirements
      • Had completed at least 6 months of a structured weight loss program in last 2 years
      • Were recruited from local weight loss clinic and fro community with flyers
    • Assessment at baseline and 3 months later
      • 8 self-report and 3 objective measurements (e.g., breath-holding, BMI changes, weight)
  • 32. Lillis et al
    • Targets for change
      • Weight-related stigmatizing thoughts and distress
      • Clarification of life values
      • Identification of barriers to values behavior
      • Fostering of behavioral commitments related to life values
    • Intervention materials: ACT Workbook
  • 33. Lillis et al
    • Results
      • No pretreatment differences between groups
      • Less psychological distress
      • Better quality of life
      • Lower levels of weight-related stigma
      • Greater weight loss in ACT condition
  • 34. Lillis et al
    • Conclusions
      • Without any focus on weight control per se, the ACT intervention had impact on stigma
      • At the 3-month mark, the ACT group had improved significantly more on all outcome measures than the waiting list control
      • Changes in stigma, distress, and quality of life could not be attributed to changes in weight, suggesting that the ACT intervention had an independent effect
  • 35. Tapper, K., et al (2009). Exploratory randomized controlled trial of a mindfulness-based weight loss intervention for women. Appetite, 52 :396-404.
    • N = 62
    • Beginning BMI (22.5 to 52.1)
    • Participant requirements and recruitment
      • BMI of over 20
      • Over 18 years of age
      • Actively attempting to lose weight
      • Recruited via advertisements and articles in local papers, in community, and via website
  • 36. Tapper et al
    • Measurements
      • Questionnaires, BMI, physical activity, mental health, qualitative data
      • Baseline, 4 months, 6 months
    • Groups
      • Intervention group: invited to attend 4, 2-hour workshops (N = 31)
      • Control group: asked to continue with their normal diet
  • 37. Tapper et al
    • Intervention components
      • Values
      • Cognitive defusion
      • Control agenda
      • Acceptance/willingness (instead of avoidance)
      • Mindfulness/self-awareness
      • Committed action
      • Review
  • 38. Tapper et al
    • Results
      • At 6 months ACT group showed significantly greater increases in physical activity
      • At 6 months there were no differences in weight loss or mental health until 7 people who said they never used the principles were excluded; then results showed significantly greater reduction in BMI.
      • Reductions in BMI were mediated primarily by reductions in binge eating
  • 39. Tapper et al
    • Conclusion
      • Qualitative data suggested that the most successful part was the cognitive defusion component, especially when used with regard to exercise
      • Participants reported some difficulty in understanding the acceptance/willingness component of ACT
  • 40. Forman, et al. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: an analog study. Behavior Research and Therapy, 45 :2372-2386.
    • N = 98 (Mean BMI = 25)
    • Participants: undergraduate students
    • Hypotheses:
      • Craving ratings will predict consumption of chocolate
      • Scores on the Power of Food Scale (PFS), which measures individual susceptibility to the influence of food being present), will predict cravings and chocolate consumption
      • Intervention ( acceptance-based strategies vs. control-based strategies vs. no intervention) will differentially impact craving and chocolate consumption
  • 41. Forman et al
    • Intervention
      • Subjects were given transparent boxes of specially marked chocolate Hershey’s Kisses and instructed to keep the chocolates with them, but not to eat them, for 48 hours
      • Then subjects were randomized into one of three groups
  • 42. Forman et al
    • Groups
      • No intervention, i.e., told not to eat chocolates
      • Instruction in control-based coping strategies, i.e., distraction and cognitive restructuring, based on LEARN manual
      • Instruction in acceptance-based coping strategies, i.e., self-awareness, cognitive defusion, and acceptance of urges and cravings without acting on them
  • 43. Forman et al
    • Measures
      • Power of Food Scale (a self-report measure of psychological sensitivity to the food environment)
      • Food Craving Questionnaire (a self-report rating of chocolate cravings)
      • Other researcher devised Likert scales
      • Surreptitiously-recorded chocolate consumption (i.e., collection of boxes of chocolates and counting of missing kisses)
  • 44. Forman et al
    • Results
      • There was a high overall abstinence rate of 91%
      • Subjects who experienced higher craving frequency, intensity, difficulty, and distress were more likely to eat some of the chocolates
      • Higher scores on the PFS predicted greater cravings and food consumption
      • Effect of the intervention depended on how susceptible subjects were to temptation, with ACT strategies associated with better outcomes among those with highest susceptibility
  • 45. Recommendations for Further Study
    • Russ Harris. (2006). “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy”. www.actmindfully.com.au/upimages/Dr_Russ_
    • Harris-a_non-technical_overview_of_act.pdf
    • Russ Harris. (2009). ACT Made Simple .
    • J. B. Luoma, S. C. Hayes, R. D. Walser. (2007). Learning ACT .
    • Steven Hayes, Kirk Strosahl, Kelly Wilson. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change .
    • Steven Hayes, (2007). ACT in Action , DVD Series.