Balancing Acceptance and Change in Eating Disorder Treatment

By Meghan Vivo

At some point in our lives, we learn that some things in life we must accept, and some we should work to change. Finding this balance between acceptance and change is a lifelong struggle for anyone in a relationship or marriage, anyone who dislikes certain characteristics they possess, or anyone facing drug or alcohol addiction or other mental health issues.

Individuals with eating disorders, who often struggle with rigid, perfectionistic thinking, poor body image, and low self-esteem, have made great strides in treatment that emphasizes finding the balance between accepting certain realities while modifying behaviors that aren’t meeting the patients’ needs in healthy ways.

At Center for Hope of the Sierras, a renowned eating disorder treatment program for women ages 16 and up, Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT), as well as a number of other therapeutic approaches, are utilized to help eating disorder patients balance the need for acceptance and change as part of the recovery process.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) combines cognitive and behavioral therapies to teach people healthy ways to manage painful emotions through acceptance and change. Originally developed in the 1970s by Marsha Linehan, Ph.D., to treat borderline personality disorders, DBT has been adapted in recent years for the treatment of drug and alcohol addiction, eating disorders, and other mental health issues.

At its most fundamental, dialectic theory seeks to bring balance to contradictory ideas, such as right and wrong, all or nothing, acceptance and change. This balance requires individuals with eating disorders to admit that there are facts about themselves and life in general that cannot be changed, including past traumas, imperfections, or perceived failures. Rather than try to escape or numb painful emotions, patients must acknowledge negative feelings and learn coping mechanisms and distress tolerance skills to respond more effectively.

Similarly, the DBT therapist works to validate and accept the patient’s emotions, experiences, perceptions, and coping mechanisms as they are now, while simultaneously working toward behavioral change. It is a delicate balance, as clearly certain eating disorder behaviors are destructive and need to be challenged, but at the same time the patient needs to feel understood and validated in order to respond to treatment at all.

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is another approach used to treat anorexia, bulimia, and binge eating disorder that emphasizes acceptance and change. The Association for Contextual Behavioral Science describes ACT as “a unique empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility.”

Individuals with eating disorders tend to be rigid rather than flexible in their thinking. In the same way eating becomes an all-or-nothing endeavor, they approach life with the same black-or-white thinking. Thus, finding a balance is important not only for the treatment of the eating disorder but also in the way patients approach life.

ACT is a form of therapy, notes the ACBS, that encourages the use of “metaphor, paradox, and experiential exercises [to help] clients learn how to make healthy contact with thoughts, feelings, memories, and physical sensations that have been feared and avoided.” Instead of trying to avoid or escape painful emotions or experiences, ACT emphasizes nonjudgmental acceptance of thoughts and feelings while changing behavior to better serve the individual’s life goals and values.

Putting Acceptance and Change into Action

Because individuals with eating disorders are typically disconnected from their feelings, treatment often begins with helping patients identify and talk about hunger, sadness, loneliness, and other feelings. At Center for Hope, patients confront their fears surrounding food by participating in individual and group therapy as well as cooking classes, restaurant and grocery store outings, and other “exposure outings.” At the same time they’re faced with the need to accept difficult emotions, they are learning skills to change the way they cope with those feelings.

“Eating disorders are both all about the food and nothing about the food,” says Leah Leonard, Ph.D., the clinical director at Center for Hope. “There are deep-seated psychological issues that have nothing to do with food but have manifested in ways directly related to food. In treatment, patients need to address both the emotions and the skill deficits they have around food, such as understanding portion sizes or preparing and eating a meal.”

The therapists at Center for Hope work with eating disorder patients to accept their bodies as they are, along with the varied emotions and thoughts that are part of daily life. Rather than judging parts of the body or certain emotions as good or bad, patients work to accept rather than resist reality. The targets for change include the restriction, binging, purging, and other harmful behaviors that may seem to fill an emotional need in the moment but are ineffective in fulfilling the individual’s needs and wants in the long term.

While eating disorder patients are learning to love themselves and accept who they are, they work with their therapists to put that acceptance into action in their involvement with others. Rather than judging friends, family members, or even strangers, patients practice acceptance. Instead of resuming old patterns of communication, they spend time in family therapy getting to know their parents and loved ones in a new way.

In family therapy, parents, siblings, spouses, and loved ones also learn to balance the concepts of acceptance and change. With guidance from a skilled therapist, family members become educated about the functions an eating disorder has served for their loved one, rather than trying to prove a point or be “right.” Together, the families at Center for Hope learn to accept one another as they are, while identifying patterns that can and should change for the benefit of everyone involved.

A Focus on Values

“Eating disorders are all-consuming of a person’s time, focus, and life,” explains Dr. Leonard. “Women suffering from eating disorders need something to turn toward instead of the eating disorder. If we expect them to stop focusing on the eating disordered thoughts and patterns, we have to give them something else to think about.”

And the staff at Center for Hope does just that. Patients spend time thinking and writing about their goals, interests, and values, whether that is helping people, spirituality, relationships with family and friends, or something else. “We ask, “What is your passion? What do you value? What would you be thinking about if you weren’t thinking about your eating disorder?” says Dr. Leonard.

Often, patients don’t have the answers to those questions yet. That’s why Center for Hope patients are constantly exposed to new activities and are asked to experiment with their values during treatment, so that they have an outlet to turn to when formal treatment ends and regular life resumes. Based on the patients’ interests, the staff also coordinates weekend outings in the community during which participants can explore their interests in art, theater, community service, and other areas.

“For someone with an eating disorder, it is terrifying to imagine living without the disorder. For this reason, treatment is about more than gaining weight, learning to cook and prepare meals, or identifying and talking about problems. It’s about all of those things, but it also requires learning a new way of living,” says Dr. Leonard. “By identifying your values, you begin to develop self-worth, which is the start of a real life-altering healing process.”