Values in ACTion: Navigating Recovery during the Holidays

As the therapeutic cornerstone of ERC’s adult treatment approach, Acceptance and Commitment Therapy (ACT) moves away from the notion of “changing cognitions” and toward how people can live a valued life in the presence of negative thoughts and feelings. Working within this framework to help patients accept their thoughts and feelings, choose a valued direction for their lives and take action toward that end not only facilitates insight, but can be a powerful catalyst for meaningful behavioral change in the eating disorder treatment environment. The principles of ACT compassionately address the major maintaining factors of an eating disorder, including rigidity, inability to see the “big picture,” isolation and most importantly, emotional avoidance, with the ultimate goal of helping patients create a rich and meaningful life while accepting the pain that inevitably goes with it.
ACT is a particularly effective approach to employ during the holiday season. Stress can be a powerful catalyst for eating disordered thoughts, and the holidays bring heightened exposure to common eating disorder triggers:  high-calorie seasonal fare, food-centric gatherings of friends and family and hectic schedules packed with traditions and pastimes. This combination can evoke anxiety and strong emotional responses, and can underscore painful relational dynamics.
“Recovery is difficult without a genuine understanding of why you’re doing it—this is true every day of the year but especially during the holiday season,” explains Bonnie Brennan, MA, LPC, CEDS, Clinical Director of Eating Recovery Center’s Partial Hospitalization Program for Adults. “Sticking to a meal plan during holiday meals, being in their body all season and engaging with friends and loved ones can be stressful, and ACT helps patients to remember what is truly important to them and what they are hoping to accomplish by doing all that hard work.”
The three stages of the ACT approach can help patients navigate the holiday season and sustain progress made in the treatment environment:

• A: Accept your thoughts and feelings and be present (“I accept that my holiday does not have to be perfect” and/or “I accept that my recovery may not be perfect during the holidays”).
• C: Connect with your values. As you’re looking at how to spend your time this holiday season, focus on what is truly valuable to you and what gives your life meaning (“I value honesty” and/or “I value meaningful connections with the people I love”).
• T: Take effective action that aligns with your values. Spend your time doing things that are meaningful to you, and don’t feel obligated to engage in events, pastimes or traditions because you think you should or because others insist it is important (“I am willing to practice direct communication” and/or “I will not spend time with my loved one who quotes clichés about recovery, gives unsolicited advice and dismisses my feelings”).

To support patients this holiday season, encourage use of these simple ACT-based exercises:

• Complete the Valued Living Questionnaire 2. This is a great activity that helps patients reconnect with their values during the holidays, as well as identify goals/resolutions for 2017 that support the creation of a rich and meaningful life.
• Practice mindfulness with these simple strategies:
• Count your breath. Close your eyes and pay attention to your breath, with an inhale and exhale counting as a single breath. Notice when your mind wanders, bring your attention back to your breath, and begin again at one.
• Quash negativity. Notice when a negative thought enters your mind. Take a moment to stop, notice that it is just a thought, and that—like the song you don’t want to listen to that pops up in your head—letting it be there and not attending to it is your best strategy.
• Observe your surroundings. When you’re feeling flustered, or at regular intervals during the day, take a full minute to focus on a natural object—your house plant or a tree outside your window, for example. Take in the beauty and energy of nature for as long as your concentration allows.
• Self-sooth and distract. TPP skills (Temperature, Paced Breathing, and Paired Muscle Relaxation) calm us physiologically, which can keep distress from disrupting our productivity. Splash cold water on your face, or put a frozen rag on the back of your neck. Practice paced breathing to relax (drawing out your exhale), or do progressive muscle relaxation while breathing from your diaphragm. The physiological response helps to ground us and bring us back to a state in which mindfulness is possible.
• Create a grounding kit and take it with you to holiday events. Stock the kit with various calming items that that help you connect with your senses, including Altoids, lavender oil and a smooth stone. Clear your mind and take notice of the taste, scent and feel of the objects.

In addition to being a valuable therapeutic intervention during the holidays, ACT brings powerful benefits when used with eating disordered patients throughout the year. Specifically, ACT effectively targets co-occurring trauma, engages families as partners in recovery and helps clinicians avoid burnout.
ACT as a tool for addressing trauma
ACT addresses trauma, which is common among eating disorder patients. The ACT perspective acknowledges that no one is taught the skills necessary to be able to tolerate pain and function after a traumatic event and that it is often necessary give people tools to change their relationship with the difficult emotions so their lives are not ruled by them and they are free to make the choices toward their valued lives. ACT specifically includes each of the components of PTSD treatment that are known to have the most effective outcomes in the treatment of trauma, including psycho-education, anxiety management and exposure/tolerance/acceptance work.
ACT as a tool for engaging families in recovery
Patients are greatly helped in the recovery process by families that are willing to learn about their dynamics and better understand the how to be partners in recovery. While families do not cause eating disorders, it is important to understand the eating disorder’s function within the context of the family system. Many well-meaning family members view their role in treatment as helping to “fix” the eating disorder, which tends to be generally counterproductive. Mental illness is not logical, and efforts to “fix” create power struggles and rigidity in family dynamics, or magnify existing issues within the family unit. Rigid relationships damage connection and block values, and rigidity maintains the eating disorder. Family members cannot fix an eating disorder, they can only support their loved one. However, in providing support for others, uncomfortable and unwanted feelings may arise. Within an ACT framework, family members, friends and other loved ones are viewed as partners in recovery, and they are encouraged to work ACT with their loved one. The goal of ACT in family therapy is to provide the tools and strategies to help families make room for whatever thoughts or emotions come up by increasing connection and flexibility through three key tenets:

• Open up. Relationships often give rise to painful feelings, and when that happens, we try everything we can do to get rid of or avoid those feelings. ACT gives loved ones the skills to confront those feelings—not change the feelings themselves, but rather change their relationship to the feelings. Making room for unpleasant feelings and sensations instead of trying to suppress them or push them away is a parallel process for patients and families alike—while individuals struggling with eating disorders have to accept that they have an illness, families must also move through a process of acceptance—of their loved one, of their loved one’s illness and of their personal thoughts and feelings that occur as a result.
• Be present. It’s easy to harp on the past or worry about the future, but this thinking fills up our minds with clutter, and keeps us from connecting with the present moment and acknowledging our current thoughts and feelings. ACT recognizes the importance of connecting with the present moment and challenges family members and loved ones to be mindful, not have a full mind, when engaging in family therapy. Mindfulness can mean different things to different people, but it will generally involve awareness, engagement, noticing and observing. There are so many therapeutic benefits to being present, including increased awareness, clarity and acceptance of our present-moment reality.
• Do what matters. Eating disorders often highlight pain, frustration, guilt and inauthenticity in the family unit, and many loved ones tend to express how they believe they “should” feel rather than be honest about the illness and how it truly impacts their lives and relationships. Doing what matters within the framework of ACT means articulating values, and aligning thoughts and behaviors with those values. Values help us explore who we are and what’s important and meaningful to us. In a sense, values are like glue that binds the tiniest actions to the biggest long term goal. When our values are clear, we can identify the committed action that is necessary to move us in the direction we want to go. In the family therapy setting, this action doesn’t have to be a grand gesture—instead, loved ones can ask themselves, “What is the smallest, easiest step I can begin with?” If the value is honesty, the committed action might be as simple as, “I can be honest and authentic during this family therapy session.” Similarly, the committed action for the value of connection might be, “I will stop engaging in helping strategies that backfire, like quoting clichés about recovery, giving unsolicited advice and dismissing my loved ones feelings.” Committed action is all about taking action in line with our values, and doing so regardless of how many times we may veer off track.

ACT as a tool for avoiding clinician burnout
There is often an expectation of a “cure” when patients enter the treatment environment, and that can result in a lot of pressure for the clinician treating eating disordered patients—we don’t have magic powers to heal our patients from their complex illnesses, and we all know that getting well takes commitment and a lot of hard work. In the context of ACT-based treatment, the therapist really serves in more of a coaching capacity with regard to their patients. We like to say we do ACT “with” our patients, not “to” our patients.  Every patient we come into contact with is an opportunity to increase our own psychological flexibility.
Many of us may have been trained to follow a directive, control-oriented approach that attempts to motivate patients to change based on fear or relief-seeking strategies. These approaches can be exhausting for clinicians working with eating disorders and leave them feeling responsible for the outcome of treatment. ACT really engages the patient in their own recovery process with the guidance and support of their clinician—it teaches them to use their values as a compass and helps the clinician let go of power struggles and battles of right and wrong, as well as the responsibility to change the patient’s thinking and behavior. We are assessing the functionality of behaviors with the patient rather than dictating to them what we believe they should do with their life. This is empowering for the patient, as they can then make the choice to commit to behaviors that take them towards a meaningful life rather than doing it because you say so or because they don’t want to “get in trouble.”