Taking an ACT Approach to Disordered Eating

As an expert in Acceptance and Commitment Therapy, I like to see myself as a psychological flexibility guide. I work with clients to get unstuck from painful patterns of avoidance and move towards a life that has meaning and purpose.

My graduate research was in appetite awareness training. This is a cognitive behavioral approach to being able to listen to your hunger and fullness cues, then using those cues to guide your eating. That was a doorway for me into becoming interested in acceptance-based and awareness-based approaches to healing our relationship with food and weight.

I went on to explore dialectical behavior therapy for eating disorders and found some of those approaches incredibly helpful in helping my clients navigate the emotional dysregulation that's associated with struggling with food and weight, but it was ACT that has transformed my understanding of working with clients in this area, because ACT offers an approach that is flexible. You can show up with any background, whether you’re a gestalt therapist, psychodynamic therapist, or even a CBT therapist, and find value in an ACT approach.

If we think about psychological flexibility, it’s your ability to pursue what matters even in the face of obstacles and self-critical thoughts. Building psychological flexibility is our goal in working with individuals who are struggling with their body image and eating concerns. Let me give you some strategies you can use with your clients. These are drawn from the six core processes of ACT so that you can get a little taste of how this approach can be used.

The Use of Metaphor

Metaphor has been used in working with body image and recovery from disordered eating for a long time. It’s is a beautiful and wonderful way to talk with our clients about difficult topics. It's also a wonderful way to use language to get around language.

One of the basics of ACT is something called “relational frame theory.” It basically goes back to our development of language and how we can get stuck in our own self-story or even use language as one of the problems that contributes to our suffering.

One of my favorite metaphors is the log metaphor that comes from Anita Johnson. In the log metaphor, we tell the story of somebody that is going down along a river, and the river gets very rocky and rough. During that rough patch, they grab onto the log. The log in in this example could be your client’s relationship with food, like overeating to navigate distressing thoughts or restricting food.

Eventually, the river evens out, and your client is still holding on to that log. Maybe your client is coming to work with you because they're so tired of being on a diet and binge cycle. Dieting is their log, and we’re going to encourage clients to let go of it.

In this metaphor, you could flesh out with a client what their log is and what letting go would look like. What rough waters were they in? When did their struggles with food and weight develop? What is it they want to swim towards?

You can flesh out this metaphor without having to go into the concrete aspects of their disordered eating in a judgmental way. Rather, this metaphor allows you to take a more distanced perspective.

I love the use of metaphor, because as a clinician one of the things that you can do is get a metaphor that really fits for your client and then use it over and over again. I've had clients where we’ve talked about their eating disorder being like a glove that fits them. They pick it up and put it on, and it feels really good to be in that glove, but the glove also prevents them from feeling the world. We can come back to that metaphor again and again, and it allows us to talk about their disordered eating without being entangled in it.

It’s important when you're using metaphor with clients that you choose a metaphor that fits them. For example, say you’re working with a tennis player. You could say, “It really feels like we're volleying back and forth with your thoughts about food. What would it be like to not return the serve?” That kind of a metaphor is a quick and easy way to start to get a little bit of distance. It allows us to look at our thoughts as something that we're battling with and allows us to reflect on how we could do something different.

It's also important not to mix metaphors. I might start talking about the tennis metaphor, but then I mix it up with the log metaphor, and now my client is confused. Choose something simple that a client can relate to. Then you can bring that metaphor up over and over again as a story line that you can anchor on during your sessions.

Taking a New Perspective

Another practice that I find helpful in working with weight and eating concerns is the practice taking a moment to appreciate how your client’s relationship with food or their body has served them. In ACT, we call this “functional contextualism.”

Let’s start by unpacking the “functional” part of this phrase. We don’t do things without reason. We do things because they’ve worked for us in the past. For example, maybe your client started restricting food because at the dinner table as a child, their parent was struggling with alcohol. Perhaps a different client learned that comforting themselves with food helped mitigate feelings of shame or trauma.

The “contextual” part of this involves looking at what context these behaviors show up in. Let’s look at the example of holiday eating. A lot of us are returning to what Geneen Roth calls our “refrigerators of origin.” We’re returning to the environment where some of our eating concerns may have initially developed, and we’re also in social situations where we may experience more social anxiety.

This is a context where your client may be more likely to use strategies that have helped them in the past. Going back to the log metaphor, this is where you can help your clients start to see the function of their overeating. It’s serving some purpose for them, and you can help them unpack that.

There’s often a cue that triggers the disordered eating or negative body image. There’s a behavior that your client engages in which often functions as an attempt to get rid of a difficult feeling, trying to control a thought, or trying to get rid of a difficult feeling. It has an avoidance quality to it, and it may bring short-term relief, but it doesn’t lead folks they want to live in the long term.

It can be helpful just to start to talk with your clients and helping them see their relationship with food and eating as a sort of red herring. Let me explain.

I live in the Santa Barbara foothills. When you drive past the vineyards that have an organic approach to farming, they often plant a rose bush at the end of each line of grapevines. I remember asking someone once why the rose bush was planted there. What I found out is that the rose bush is planted there because it’s super sensitive and vulnerable to pests. It will actually show the damage of pests or disease before the grapevines do, and it’s an indicator that something needs to be tended to.

Sometimes when a client comes in, they’ll say something like “I feel fat.” That could be the rose bush telling us that there’s something else going on here. Maybe what the client is really expressing is that they feel vulnerable and worried they won’t fit in.

When they focus on “I feel fat,” they don’t have to process what’s underneath. If we just take the rose bush at face value, we lose the chance to explore the client’s feelings behind their statement.

I encourage you to look at the function of behavior with your clients. And you might notice I just used a metaphor there. It may have helped you understand the concept in a different way!

One Eye In + One Eye Out

I use this third practice all the time in my own life as a therapist. I encourage my clients to use it as well whether they're struggling with eating and weight concerns or just navigating the world.

This practice is incredibly beneficial especially for folks that are struggling with eating and weight concerns, because oftentimes they’re either hyper focused on the inside or outside. Maybe they struggle with anorexia and are super focused on the feeling of being full and it's aversive to them. Or maybe they’re super focused on what's going on around them, completely tuning out their hunger or fullness.

“One eye in + one eye out” is a strategy that helps our clients keep connected with their emotions and their interoceptive awareness. It gives them the ability to pay attention to what's happening inside while also having the flexibility to pay attention to what's happening in the world around them. Ultimately, they develop the flexibility and ability to toggle back and forth and answer the question: what do I need right now?

Being able to pay attention to this inner voice while also maintain a sense of connection to others is incredibly helpful in recovery. It’s not all about “two eyes out” or doing something for some extrinsic reward. It’s about reclaiming your feelings in a flexible, compassionate way.