Treating BED


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Treating BED

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