Acceptance and Commitment Therapy

Eating Recovery Center’s Adult Services embraces Acceptance and Commitment Therapy as a valuable treatment intervention for all patients, including those with a history of eating disorders or trauma. In this presentation, Bonnie Brennan, MA, LPC, CEDS, Regional Managing Director Clinical at Eating Recovery Center, explains how Acceptance and Commitment Therapy (ACT) swiftly and effectively addresses the major factors maintaining an eating disorder, including rigidity, inability to see the big picture, isolation and most importantly, emotional avoidance, and how ERC utilizes ACT in eating disorders treatment.


Bonnie Brennon:
Can everyone hear me okay? Welcome to our virtual Family Days presentation on Acceptance and Commitment Therapy, and I'm really excited to be here. I'm Bonnie Brennon, I'm the Regional Clinical Director here at Eating Recovery Center for our adult. And we are going to talk today about a few things that you might want a pen and paper to write down. I'm going to have you practice just a little bit, just a wee bit, of some of the things that the patients might practice. Nothing that you're going to be asked to share with others, just some information you might want to think about for yourself. So if you have a pen or paper, if you have a phone you want to make notes in, please go ahead and get that now.

A lot of the difficulty in working with eating disorders comes from our own feelings of fear or helplessness or shame. Today we're going to talk about how to work with Acceptance and Commitment Therapy just for yourself and some of what your loved ones are doing, as a way to think about what we can do. What are the things that we can do to move forward to a life that's worth living and that's satisfying, and helps us to move away from a focus on getting rid of the problem.

Eating disorders are enduring mental illnesses. They might be there for a long period of time available in the brain to think about, and so we want to go with an approach that overrides just the problem solving, and gets into the heart of why you would recover, why would you spend so much time eating and drinking and not getting rid of food, there has to be something that's worth it for you that's in it for you. So we'll talk about some of those things today.

So some facts about Acceptance and Commitment Therapy, there's the founder, Steven Hayes. He is still teaching at the University of Utah if you want to go get a degree in behavioral psychology. He still has a few years left of him teaching, I think. And it was developed in 1982. There are now over 350. Actually I have to edit that, 350 we jumped the beginning of the year. Randomized controlled trials, so what that means is that we've actually studied the science behind the processes we're going to talk about today, and over 350 studies in all kinds of areas. Depression, eating disorders, substance use, smoking cessation, trauma.

It's a trans-diagnostic approach, meaning that it crosses all kinds of mental health challenges with a worldwide scope. There was a nice study from the Sudan recently that used ACT in not even a written form, in a picture form, pictorial form. A brief intervention of ACT greatly improved the quality of life for ... The World Health Organization is going to be citing that as a study, you can look that up. We have an association too, for Contextual Behavioral Science if folks are willing. You can join that, the website is right there, It has its own professional journal.

We say the word "acts" like ACT, unlike the other behavioral therapies where we might say DBT or CBT, ACT is just pronounced ACT and then it reminds you about a core principle that we'll talk about. And we also have a measure to the Acceptance and Action Questionnaire, so we have the scientific measure to measure its effectiveness. I just want to take you backwards a little bit so you can understand what we do in terms of behavioral therapy. So, and as ... in the world of psychology, behavioral therapy came about, most of you might have heard the term Pavlov's dog for example, there's a little picture of Pavlov there.

And these scientists first looked at how we can influence what people do on the outside, so what we might do behavior wise with our bodies that we can change those patterns. If you ever watch on a camera somebody behaving with their body, what can we do to influence that. A classic study was that Pavlov trained the dog to get dinner associated with a bell, and so then all he needed to do was ring the bell and the dog would start salivate anticipating dinner. So we were able to train the behavior of salivation stimulated by the ringing of the bell.

Then the second generation of behavioral therapy, actually this is a big, important jump. The guy on the left there, the left hand side of your screen, Aaron Beck is actually still alive, he's 98 years old, lives in New England. But they focused on understanding that the contents of our minds, things inside of our head, are actually ... their thoughts are considered behaviors as well, and we can choose how to focus on thoughts as a way to make changes that we might want to do in our lives.

Then came the third generation, which is where we are with Acceptance and Commitment Therapy. The challenges of the second generation of changing thoughts is we got stuck in a belief that we could actually eliminate thoughts from our head if we just argued hard enough with them. And as any of you know who may have had adolescents that you've argued with, sometimes the arguing with the thought only serves to make it stronger. The time spent in challenging no, let's say you don't believe, or all of us might have a sense of ourselves that is something that we don't believe in.

Maybe one thing for me I might say, for many, many years I wanted my hair to be a certain way and I believed I couldn't wear short hair, and no matter how much somebody would want to challenge me, about like, "No, you look really great in short hair, I think you look good in short hair," I would strongly believe no and then argue more about why not, why I shouldn't cut my hair. I finally did when I was pregnant, it was really cute. But it's high maintenance, short hair is high maintenance, so I grew it out.

But, and when you think about it with our patients or your loved ones, that sometimes arguing with that eating disorder does that, doesn't it? They say, "I feel fat," and you say, "You don't look fat," or "Honey, you're perfect, I love you just for the way you are," it doesn't actually get rid of that feeling for them that they feel like they're heavy or feel like they're too [inaudible 00:07:36]. And we're going to talk a little bit more about that.

If you're interested in more of the science around it, you might want to think about picking up this fun little read, Relational Frame Theory, it's very high level. I'm being facetious when I say a fun little read. It's very good material, but it takes at least in my mind, a lot of brain thought to understand what they're talking about. But it's a theory of how human beings have learned through language, and the challenges that language also brings to the table. So in our ability to speak and have thoughts and words in our head and our ability to write, we can learn about things that other animals and mammals can't do.

You can read a book for example, pick up a cookbook and learn how to make a lemon souffle without ever having tried it before, just by reading the words that language is providing, we learn how to do things. Other beings, other mammals have to learn experientially or be taught by the pack for example, or be taught by their other dogs or cats around them on how to do the things that animals do, but we can actually learn through language. And that also means that we can learn stuff that's not useful for our optimal functioning.

Think about eating disorders and learning about diets that seem to promise some kind of better life to them, and then could really be a trap for them, really cause them a lot of pain. And a lot of times there are arbitrary rules that are made up that the human being starts to follow without question. So we want to put a little space into those types of things that happen in the head.

And then a basic assumption of ACT is that in all humans, we will experience suffering. There's not a world that I am aware of that you get to live in where something doesn't happen that brings us to our knees. COVID brought us to our knees. These riots bring us to our knees. There's so much going on, we're in a very being brought to our knees kind of society right now. And then there's some things that bring us to our knees that are just beautiful. If you've ever had a moment of love or connection or enlightenment where you thought oh my gosh, that ... it's just something that my mind hadn't considered until now, or what a gift. The human experience can be full of pain and full of joy as well.

And for those of us and our folks right now, your folks that you're here to support, their eating disorder is oftentimes an attempt to solve another problem. It's a problem, it's a solution that has become a problem and their attempt to solve whatever it is that brings them to their knees, maybe it's fears about belonging, fears about being loved, has now become a problem as well. So at Eating Recovery Center, we want to try to address not just how to not have an eating disorder, but what is the problem or problems, oftentimes it's many, that the eating disorder is attempting to solve.

Because as soon as we take that eating disorder away or we help them with our schedule and our programming, and tell them exactly when to eat and sleep and the eating disorder isn't able to function the same way it has, all the other stuff is going to come to the surface. All the feelings, all the pain boils up like when you make chicken soup from scratch and all the stuff comes to the top, all the gunk comes to the top, but that also, process of cooking also provides the savoriness of the soup. So part of our job and part of our ... as support persons and as clinicians is to let them have the gunk come to the top, come to the surface so we can understand what the eating disorder was treating.

I'm going to give you a very brief ... here's a step, part one of you participating. I'm going to give you a very brief story, and if you want to ... you're welcome at this moment if you have your camera on and you want to turn it off so that you can go into your mind in a place of imagining. And the story I'm going to tell you today is a story about a bus driver, the story of you being the bus driver. There's a picture on the screen if you want to look at it, of a red bus, beautiful red bus. And today, you, a trained and competent and experienced bus driver, is about to embark on a journey on a magic bus.

And the reason this bus is magic is because all you need to do is get on the bus and get behind the wheel and imagine where you want to go. You don't need an app, it doesn't have a Garmin, it will just take you in that direction without really much effort on your part. You just have to steer the steering wheel and press the gas, and off you go. So this is really exciting. You've got a new jacket to get on your new bus, your new magic bus, and you're about to board it when something unexpected happens. Three scary characters appear, and there's three of them. You didn't anticipate this, and they look kind of scary, whatever scary looks like in your mind when we ... I do this story with the patients, I might say, "Imagine it's your fear foods, an embodiment of your fear foods, pizza, French fries and a jar of peanut butter."

But three scary characters appear and say, "Hey, we would really dig it if you would let us get on this bus, and we want to ride on this bus." And you try to say, "No, no. There's no room on this bus for you today, this is just a special training tour. I'm not allowed to let you on the bus." And they press closer and start to really violate your space and say, "No, you're going to let us, there's three of us and one of you, and you're going to let us on this bus or you're not going anywhere." So you strike a deal with them and say, "I'll let you on the bus, but you better go into the back and stay out of sight because I just can't deal, I just can't deal with the sight of you, the experience of you. So as long as you go in the back of the bus and you stay out of sight, we have a deal." So they agree and they get on the bus and they go, and they stay out of sight. And it's okay for a while, you put the bus in gear and it's true, all you need to do is imagine where you want to go and it's happening, and the path just seems to appear in front of you without effort of thought on your part. It feels really good and amazing.

Just as you're about to settle into that sweet spot of comfort, you noticed in the rear view mirror that one of them starts creeping up the aisle and you get scared and tense, and then start to doubt your direction, where you're going, and then it starts to add to your doubts saying, "I don't know if you should be driving. Why did they pick you to drive this bus? Are you sure you have the right training? I don't like the speed that you're going, this direction seems aimless. Is this really what you're supposed to be doing?" Inserting self doubt, and you get scared and frustrated and say, "You were supposed to be in the back of the bus. We had a deal, go out of sight. What do I need to do to make you go to the back of the bus?" And they say, "Oh, turn left. I don't like this way, turn left." And so you do, and you get off course for a little while.

But the scary thing is out of sight, isn't it? And then you get back on course, start imagining again, get back on course feeling not quite as confident, but feeling it start to come back when the next one, this time rushes up right behind you. You can feel its breath on your neck as it tells you how much of a failure you are, that you really ought to re-think this whole thing called life anyway, because you're never going to get there. You're never going to arrive to this place that you think is going to be satisfying and meaningful for you. Why even try? Why even try? Why don't you just turn the bus around and go back and park it, and let us drive it. So you turn it around and you try to start over again.

But on and on it goes until you're in a place where there isn't even a bit of imagining of the direction you might be able to go, and that's where your loved ones are. They're bus drivers that have given up on the direction of where to go in life because of the scary characters in their mind that tell them about, you can't be fat or you have to do this with your eating disorder, and they're spending all of their time making them sit out of sight, get out of sight, get out of my mind, don't let me experience that. But they've lost their way.

So thank you. That's all the imagining that we need to do, and I think you can see the metaphor there that if we are feeling confident and we have a direction that we want to go, and we're willing to have those scary things on the bus, even if they tell us things that are distressing and troubling, if we persist in the direction that we feel is meaningful and valuable, eventually we will get there. But if our focus shifts into that not having what we don't want to have, then we can really get off course.

So what are some of the things that this eating disorder is doing to refocus us, what are some of the things that it's trying to control, or that people are utilizing the eating part that functions to help them in some way? How does it become a problem? Well, the classic eating disorder example is that the eating disorder is a way to have control or revenge or express anger. It might also be a way to numb out. If for example in binge eating disorder, the process of putting a lot of food into the body, so much so that you're kind of stopped from feeling anything because there's so much in there, allows you to check out from what might be a really busy work schedule, or the inability to say no to social engagements. An eating disorder might also function to avoid responsibility and not grow up.

A lot of our folks, they're not going to really talk with you about this necessarily, and it's hard for them even to voice it to a therapist, but the growing into an adult body that is able to have sexuality and maybe create a baby, brings up a lot of things. It brings up, will anybody ever love me? Will I be able to have kids? Will I be a good parent? What if I don't want to have kids? How am I going to support myself? Am I going to choose the right profession and right career? Maybe it's just easier to stay in a body that isn't an adult. Maybe it's just easier to stay dependent in this place that feels safe because there's so many scary things out there that I'm not sure that I have. There's a lot of passengers on that bus that I want to not have to deal with.

You can see some of the other things that the eating disorder might do to help them feel better, some self soothing. There's been some research on anorexia and [inaudible 00:20:57] persevere enduring interactions. Their brain actually is calmer when they're restricting. So we've done brain studies where we can see that the brain basically is in a state of peacefulness through their restricting behavior. So how hard is this to combat? The very thing that we need to do, have them eat and be in their body and not restrict, is the restricting is the thing that makes them feel better and we have to tell them they can't do that, right?

I was telling the process group the other day that I was running with a therapist, that they're so brave to be in treatment. I would rather have four more babies without pain medication than go through eating disorder treatment, because the very thing that terrifies them, eating, being in their body and not getting rid of it or not being able to exercise obsessively, is the thing that they have to do all day long. It's kind of like if we would take alcoholics and march them into a bar, set them up at the bar and put a bottle of Jack Daniels in front of them and say, "Hey," do you think you can develop a healthy relationship with alcohol? Wow.

We can't do that with eating disorders. We can't take the food away in that way, so they actually do have to develop a healthy relationship with the thing that's really hard. And that's why you'll see so many chapters of relapse or struggles because when life throws them the problems again, it's easy to walk into that bar so to speak. It's right there, food and body is right there all the time, we can't take it away from them. At its core, eating disorders tend to be avoidant human beings with avoidant strategies, and they spend a lot of time and energy trying to not do things, not have scary things happen, not get in trouble, not be too big, not have all that food still in the body. Eating disorder behaviors are the perfect way to not experience, because in the obsessional thoughts about food and taking the body through the process maybe of binging and purging or restricting all day, they're able to reduce the awareness of their painful mental content.

All right. So let's kind of shift gears for a second, and let's try to understand where we might get off course, and why do people develop problems to begin with. And this isn't just eating disorders, this could be for any kinds of problems that we have. Maybe it's depression or anxiety. Dr. Steven Hayes wrote a book last year called A Liberated Mind. It's referenced down below. He introduced to us the six yearnings, which were based on self determination theory, and a little bit taken from the work that's done on evolutionary theories. And these six yearnings we're going to go through and talk about what you can do, how they can become a trap, and then what you can do to get out of the trap. So briefly we'll go through each of them, the yearning to make sense of all the thoughts that are in her head. There's thoughts that are very useful in there and thoughts that are not. Some of it's just chatter and radio noise in the background.

We have the yearning to be seen and included and to feel like we're a member of a group. We're very social creatures, we yearn for experiences that make us feel something, we look for, we move towards feelings. We yearn to know that where are we are in our life journey, what am I doing with my life? Why am I here in the first place, and to freely pick and pursue the things that are satisfying and that we want to do. We might change our minds along the way. That was my whole 20s, I changed my ... I thought I was going to do something like not treat eating disorders, and I changed my mind. But it isn't until the act of going in and trying it, that you realize that you might need to change course a little bit when you're walking your body through it. And then finally, to feel that we're effective at what we're doing even if it's playing, that we do yearn to be loving and living in a skillful way.

To move my little gallery here, thanks. And then, so there's six ways that we would work at addressing where things start to get off course with those yearnings are through the six core processes of ACT, and we'll link the two together. Diffusion, perspective taking self, acceptance, being in the present moment, identifying your values and actually taking committed actions to move towards those values. Okay, so before we start with all those yearnings and the ways to move towards a life worth living, I just want to make a disclaimer right here. In anything that you're doing with your loved one in treatment, and us as professionals included, it's to encourage you to think of yourself when you're learning a new skill or a new way of trying to do something, as a toddler.

Toddlers do not expect themselves to be proficient the first step that they take. I'm not expecting you to listen to my presentation and immediately being able to implement in a competent way, all the ideas that we're going to talk about here. You are a toddler, and maybe there's just one thing that I say today that you think oh, that really clicked with me and I want to try it, and that's fine. Even if you're toddling about back and forth and not feeling very steady about things, it's okay.

Please give our patients, your loved ones the grace to be toddlers, too. If they're going to fall on their bums, they're going to touch stuff that they shouldn't touch. Those of you that spend time with a toddler know, some of them just are ... my boys were both just like, "Let me go and explore the world without you right now." So I had friends who had toddlers that were a little bit more tentative, and it took them a little bit longer to be brave enough to venture onto the playground. So let's think about what our task is and what our loved ones' tasks are as being toddlers, and being willing to accept their failures.

Then another thing that happens in the toddler stage is that they have a ... learn to walk is kind of like through this rocking behavior, they're ... and when they turn around they don't know how to pivot smoothly, they kind of turn themselves around in a way that might be a little bit ungainly. Maybe they turn too far and fall over. But with proficiency, with practice, they learn then how to walk forward, and then with the ball of their foot, pivot neatly so that they don't have to put all that energy into changing course. And that's another thing too, that as you practice more you'll be able to pivot more smoothly. You'll be able to turn from getting in the power struggle for example, into maybe a exchange or a conversation that is not energetically the place that you want to be.

All right, so let's talk about the yearnings. So our first yearning was the yearning to make sense of all the mental chatter. And what goes wrong with that? That's natural, normal, all of us have that yearning. But what goes wrong? Well, when we have all these things in our head, and human beings are capable of so much content, there's so much content out there, we all know this right now because we could go at any moment of the day on the internet and read about COVID, and some of it's true and some of it might not be and some of it might just be hypothetical, and some's based on science and what do we make of it?

And in our attempt to take all this information, especially now I think more so than ever with the ability to learn about anything you want on the internet, all our kids have to do is say, "I want to know about why I should drink I don't know, alkaline water," and go and read articles about that. And it's very humbling actually, they don't need us anymore. They don't need us to be professors or experts or anything because they can go to the internet for that. What they need from us is to help them find their way through their own sense of self.

But what goes wrong is we start to impose a false order, put rules to things so that it's easier to make decisions. And we then start to narrow our focus into the problems that don't fit into the container of that false order, and eliminate ways of being, like I can't ... for example, going back to how a diet works. A diet oftentimes has lots of rules about what you should eat and not only that, about what you should do for your life, how you should exercise when you should go to sleep, how to select food at the grocery store, when to cook what and how much. And it helps actually to narrow things down for people.

But in the process of that, they become more focused on the rules of the diet than understanding the big picture of their life, and they get trapped into a sense, or we get trapped into a sense of having to be right, and losing perspective about what might be important to us. And we can become what's called fused, fused with believing that the thing that I think has to be the way. There isn't another perspective that I'm willing to entertain. And you know that you're fused with something when it feels like it's right in your face, I have to do this or I have to think this way, and don't challenge me on it, when you're using language in the form of rules or you're giving reasons for things, even though you might not be feeling inside that those reasons are valid.

Has anybody ever tried to talk themselves into being in love? Yeah, how does that go? There are times when oh my gosh, for my family and my well being that I wish I could have talked myself into being in love, but it's just, even though it might make sense in your head, it's if the heart doesn't follow, the heart doesn't follow. So we get too trapped into the reasons for why we should be doing what we're doing, or we start making judgments about ourselves and others that aren't helpful. We're spending time in the past thinking about, obsessing about what we did wrong, how we can fix it, or future tripping, worrying about the future and not even spending time in the present moment.

So how do we get out of this trap that we're in? It's called defusion. And the trap is fusion and the getting out of the trap is called defusion. Defusion is a made up ACT word, it's not misspelled there, meaning the process of defusing from those things, those unhelpful rules, those thing that we believe so rigidly. So we focus on being more flexible in our thinking, watching what our thoughts do without immediately reacting to them, just allowing them to be there, and not allowing your thoughts to dictate behavior.

A great example that we all have had happen is when we get a song in our head that we don't want in there. It starts playing over and over and over again, and it can be kind of annoying. Maybe it's a song you want and maybe it's not. When my kids were little, there was a TV show they liked to watch, Dragon Tales it was called, and the song can be brought to mind at a moment's notice. Dragon Tales, Dragon Tales, now it's time for Dragon Tales. Right? And that song would play through my mind while they were watching Dragon Tales, even it went while the music wasn't playing. And when they were watching Dragon Tales, I was usually cleaning or getting something done. And now whenever I clean, if I'm cleaning up the kitchen for example, the song will come into my head, I linked it to some kind of cleaning ritual. But I don't want it in there. And I'm not blaming myself for it, am I. I mean, we don't generally tend to hate ourselves because a song is in our head.

And if you've ever tried to get rid of the song in your head, you know that sometimes paying attention to it and saying, "God, I don't want this song in my head," actually makes it louder, stronger, faster. Dragon Tales, Dragon Tales, now it's time for Dragon Tales. So what do you do? How do you get rid of that song in your head? Do you give it away? [Maggie 00:35:21], do you have Dragon Tales, song in your head now? I bet you do. And your friend is then mad at you, you gave away the song that was annoying you. So you can't really ... The thing of it is is you can't really get rid of the song in your head. You can wait for it to go away, you can focus on doing something else, and then in the process of doing that eventually it does go away, doesn't it, without you actually having to put planful thought into making it go away, it will go away.

Now I want you to think about some of the songs that are in your loved one's head. Maybe it's the song that I'm worthless, I'm hopeless, I'm fat, I shouldn't be here. I'm never going to make anything of myself. Those could simply be songs in the head. And sometimes, and I've done this as a clinician, I was trained as a ... in the cognitive behavioral therapy era where I would argue about that. I'm like, "Oh, you're such a wonderful human being," and, "You're going to make great contributions to the world." And in my well meaning intentions, I actually was reinforcing for them to not have the song in their head, and that maybe they were a bad person for even having the song in their head.

So we have to be careful about believing that we can get rid of thoughts, believing that there's something wrong with us even for them coming up. There are some things that we have to be planful about. If somebody's having a very loud song in their head about killing themselves, then we have to help protect them and help them be safe. Some people have that song playing in the background and any chance they could hit that button, it's like number one on the radio dial, that they can choose to have at any time and they could turn up the volume quickly on that song in the head.

So we have to be thoughtful about how much time we're actually going to give it. We want to make sure everyone's safe and taken care of, but steering the conversation towards more useful songs to have, because you could play another song, can't you? You can open up another way of looking at the world while that song is playing in the background, and start doing other things, and that's our job. It's your job and my job to open up their perspective and help them to defuse, start to think about their thinking and be more flexible in having to immediately react to thoughts. And that's called the diffusion pivot.

This is a graphic, it has a lot of information I don't expect you to memorize, but it's just showing you with a visual. There's our yearning to make sense of the world and organize our thoughts. It starts to funnel down as we impose a false order and we get stuck in this place of being right about our thoughts. I am worthless. Or, I am hopeless case. And that is all we have the mental energy left to do. But as we start to pivot away from that and show another perspective and way of being, we can actually help them move towards a greater wisdom and peace of mind.

So we're going to practice real quick a diffusion skill right now, if you're willing. So if you're willing, with your pen and paper maybe just make a mental note in your head is fine, I want you to think about, we all have these now, something that you don't like about yourself, a thought that you have about yourself, and one that maybe has been with you for a long time. I'll give you an example of one that's been with me for a long time and I kind of mentioned it at the beginning, is I have had the thought that I'm too much for a long time. I was a tomboy, I was boisterous and loud and messy, it's kind of the Arya Stark, for those who like Game of Thrones. I just didn't really fit into the girl that I was supposed to be, and I have this story in my mind that I'm too much. Sometimes it will come up and kind of get in the way of how I want to show up in the world.

So think about, do you have one of those thoughts? It doesn't have to be as energetically big as being too much, but maybe there's a thought that you've had about yourself for a long time that you're not comfortable with, you don't like having it, but yet there it is. And once you get that thought, I want you to just write it down on a piece of paper if you have one, and then I'll give you the next instruction. I'll give you a couple seconds to think about that. And you're not going to share this by the way, so don't worry about that.

So once you've written down your thought, if you have it on a piece of paper, I want you to fold it up and tuck it away close to you so in case I ask you for it again, you've got it on the ready. Put it in your pocket, put it under your notepad or wherever you want to keep it tucked away. All right. So everybody's got their thought, everybody has it tucked away. You can get it if you need it, right? You probably don't even need to go look at it, you know that it's there but you've got it, you don't have to do anything more with it, and just in doing that, you've given yourself some space from the thought of being able to carry it with you.

And carry this thought with you, I'm not going to expect you to ever get rid of it. It might be there, my too much will be there probably for the rest of my life, it's going to come up again who knows when, I'm sure within the next week or so. But it doesn't mean that I have to problem solve it. It doesn't mean I have to pull it out and put it up in front of my face and pay attention to it and think it away so hard, or shame myself for having it, because that just adds to my pain and suffering. So some thoughts we can just take with us.

All right. So moving on, the yearning to belong and connect, to be part of the group. Well, what goes wrong here? We start to get into a feeling of, if I do certain things a certain way, then I get to be part of the special club. I get to be part of the clique or the ... and it's not necessarily a bad thing. I don't want you to see that. I get to be part of the team maybe, wanting to be part of the special team. But what starts to get off course is when we start to shut down the perspective of others. Sometimes my teams here, treatments teams might think that the other team isn't quite as good as them because they are the special team, and then we know we're in a trap and we have a conversation about it.

But, or we might exclude others from our special place in the attempt to belong and connect, or we might start to feel excluded. And then in our attempt to still belong to part of the club, we might notice ourselves defending or lying or hiding. We focus ourselves on the ... our behaviors on the story we want to believe about ourselves rather than what's actually true. It's maybe hard to give up some of the things that we love to be part of this club, so we let go of things that really were meaningful to us. And then it's most painful place, we realize that the club didn't actually provide us with a sense of belonging because now we're so focused on maintaining being part of the club that we've lost connection to it in the first place, and maybe becoming alone. And eating disorders certainly thrive in aloneness. They thrive in secrecy and isolation.

So how do we help ourselves to not be eliminating possibilities for our lives, and building a self from a perspective taking place? So focus on perspective taking and it's actually not an advanced skill, but it's one that's hard to remember to do sometimes, is to take perspective of others. What must it feel like to be in your skin? What must it feel like ... One of things that when I'm really mad at somebody, oh, a person frustrated me and I can't believe they did that and would you ... I'll usually go through a process of chattering away to my best friends like, "I can't believe my sister did that to me," but eventually I get myself to a place of well, why did she do that? I'm like, maybe really trying and think about why would my sister have behaved in a certain way that irritated me. And that helps us to get out of a place of being frustrated about what happened to us, and help understand where somebody else might be.

We practice a greater sense of community when we start to take the perspective of others. One thing that we do with our community meetings here is to actually, we have exercises to help them with what might ... how might your behavior being affecting others. We understand how it's helping you or hurting you, but how might others be experiencing that? I did that with a patient last night. She was really struggling with not completing her meals, and we said to her, "You might not be able to be in the community because you're damaging other members of the community by behaving this way. You're not being a good member of the community." So it helped to actually motivate her to complete her meal and her snacks so that she could stay in the community. She didn't want to be hurting them with how she was expressing her eating disorder.

Then we get a greater connection with self and an awareness of the whole, and be able to recognize that some of the stuff that our mind is telling us is just a story, it's not true, the "I'm too much" story, not necessarily true. Sometimes it probably is, but it's not always true, and it shouldn't dictate my life. Okay, another little experience for you. How do we built perspective? And it can be as simple as this exercise. I'm going to ask you to do imagining again, so you can turn your cameras off if they're on. I can't see everybody, so I don't know who's on and who's off.

And this is just a picture of a third grader. So I want you to in your mind, picture yourself as you were in that third grade picture, it's a little awkward. Did you have all your teeth, I don't know. That looks like a sweater from the past there. But come to ... bring to your mind if you can remember, what you were like in second or third grade, and give yourself a moment to make contact with that memory of yourself, second or third grade. And once you get to that second or third grader, I want you to imagine you're watching yourself at that age.

So maybe you're in a room with your second or third grade self. Maybe it's a classroom at school or on the playground or your own back yard. And this little second, third grader you comes to you as you are now, and in their little second or third grade voice, they say the thought that you just wrote down on your paper. And if you need to get it out and look at it, go ahead but I don't think you do. So my little second grader would be saying to me, "I'm too much." Just imagine what it ... you see this little child saying your thought to you. And I want you to notice how you respond as the adult to the child.

Most of us don't respond naturally with wanting to push the child away or slap them in the face or yell at them, right? But sometimes it's what we do to ourselves as adults when we have that thought in our head. We metaphorically slap ourselves in the face, "God, stop thinking of that, what's wrong with you?" So let's go back to you see that little child saying that thought that you had written down, put in your pocket, and what are you drawn to do for that child? And most of us are drawn to do some kind of comfort, not some kind of punishment, aren't we? And this exercise is ... you can come back into ... out of imagining now. This exercise helps to build perspective of all we need to do is watch ourselves in our own minds as saying that thought as a child, and we have a different perspective on how we might want to react the next time we have our thought come up in our own heads. What do we need? Do we need the slap in the face, or do we need the loving embrace?

All right. So here's the picture of it, if you're the visual learner. We have the yearning to belong and connect, or attempt to be part of the group. We get into specialness, and then we start lying and defending and hiding and focusing on our story and how we think we should be rather than what we really are, which only serves to make us alone in the end. For those of you who have gotten the giant house and the fancy car and the great education and had the experience of being in it with no one that's around, that doesn't guarantee that once you've done all the things, that you have the feeling of belonging. And it sometimes can serve to push people away.

I like to talk to the patients about if you have a perfect house, people tend to be pretty uncomfortable visiting in your perfect house because they're worrying about making it imperfect. So the secret, this is my secret rationalization is always to have an imperfect house, part of it's because I can't achieve perfection, but also I notice that people feel more welcome when things are just not quite so perfect because they don't worry about messing up the perfect. And as we pivot away and build perspective, our self and who we want to be and how to show up in our communities, we will experience a greater connection as a whole to other humans.

So then we have the yearning to feel and experience, and all of us have this. We long to ... This is from the Titanic. If you're like my stepdaughter you may have watched it more than four times because why, why do we watch the Titanic more than four times? My mother loved to watch the ... oh, I'm forgetting, Gone With the Wind. She loved that because there was so many emotions in Gone With the Wind or The Titanic. There's tragedy, there's love story, there's rescues and things like this, and we like the feelings that are stimulated by it. And sometimes we go towards scary feelings like roller coasters and haunted houses and things like that. But when there's too much, when the volume is turned up too much, it can be startling and jarring. Even sometimes feelings of euphoria can be scary if it's way too much. So we long to feel and experience, but not too much. And some of our nervous systems are more tolerant of what that is than others.

What goes wrong is in our attempt to just feel good, which is a very Westernized society agenda, isn't it, no bad feelings, be your best self, we start to believe that there's something wrong with us if we're not feeling good all the time. That becomes an issue because we focus on getting rid of pain and discomfort, we don't let our bodies learn how to tolerate uncomfortable feelings. For our eating disorder patients right now when they start eating again, it hurts. When food has not moved through your system in an appropriate way, it hurts for it to move through appropriately naturally. And when you hear from them about how awful we're being because they're in pain from eating and we're not doing anything about it, is because sometimes the doing of alleviating the symptoms is just prolonging the food from being able to move through in a healthy way.

So sometimes the stomach is going to hurt, sometimes they are going to have gas, it's nothing wrong. We'll do what we can to alleviate the pain, but not all the time. Part of being healthy is being willing, am I willing to feel a little gas in my system to not run to my eating disorder because the minute they run to the eating disorder to alleviate it, they're going to quickly slip back into it. So our job is to help them be in pain and make it be okay. There's nothing wrong with them for being in pain a little bit. And then maybe sometimes the pain of heartbreak is unavoidable, but if we narrow our life so much that we never let ourselves experience pain, it also means we can't experience joy or love or euphoria, peacefulness. So an eating disorder is perfect for that. It shuts off all feelings, and then we don't know how to feel about anything anymore.

In the process towards allowing for feelings is acceptance, being willing to actually have it. The more we try to avoid the pain, the more we sink into it. The quicksand metaphor is the ... for those of you who have been trained on how to get out of quicksand, if you get into the quicksand, you fight it, you actually sink more. The way out of quicksand is to lie on your back and float, or stop moving so that you can spread out the weight of your body over the water molecules that are in the sand. So it's kind of what we're asking the patients to do too, is to practice some acceptance. Be in the quicksand, if you try to fight your way out of it it's just going to hurt more. And accepting this discomfort, these feelings that are floating to the surface in the service of being able to do the life that we want to do.

I just had this talk with my 16 year old son who was applying to jobs and said he interviewed at Wendy's but he told them no because it seemed like they were too busy and he didn't want to have to work too hard. So we had the conversation about ... all of us, why do you want a job? Let's remember why do you want a job? Well because I want money, he wants to save up for a car. So sometimes we have to do the stuff that's painful like wash dishes at the restaurant or work at Wendy's, or I'm not a commercial for Wendy's, it's just the place that he applied, and do hard work and be busy because it provides us with something that we want more longer term, so being willing to have the pain and the values of ... in the service of valued living and our willingness to feel it.

Then just taking a wider view of the situation, panning out from the in the moment experience of the pain, you can start to see that the possibilities can be very quite complex and beautiful ahead of you. So taking a look at if I allow this pain here, what does the world have to offer me, what am I moving towards, and getting out of problem solving of it. The visual for that is here. We start to ... we yearn to feel an experience, but when we believe that the good feeling is all that we can have, we inadvertently start to narrow it down into the feeling of nothing, emotional dysfunction. And the way out of it is through practicing acceptance of all the feelings inside, being willing then to choose, even though you have the feeling, where you want to go. And that will lead us towards a greater willingness to feel safer and participate.

We have the yearning also for orientation, for where are we in our life's journey. And what goes wrong is we start to focus on how and why to get there. Right? We focus on the past or the future, we worry and ruminate, and we're not really here in the present moment analyzing how it feels to be in the current situation. We get there ... if you've ever been ... I've experienced this when I've met a big goal that I've been working towards, or finished the race. And because I've been so in the past or in the future, even the completion of the goal or the finishing of the race doesn't even feel like anything. It can feel disconnected like, "Oh yeah, I did it. What next." I'm not even able to stop and slow down long enough to say, "Wow, I'm really proud of myself, I did that goal."

Some kids graduating from high school over the last month or so, they finished a big accomplishment, and were they able to stop and reflect. Maybe, now that COVID has slowed things down and they don't have all the distractions of the normal senior year, maybe there was actually a gift for some of them in there that they could have some time to reflect all that they've accomplished in their graduation.

So our process towards being able to orient to where we are in our journey, is to bring our bodies into the present moment and focus on useful noticing, focus our attention on being in the here and now, and using mindfulness exercises. And I'm going to show you one. We don't actually have time to go through this, but I would encourage you to practice it. You could read it to yourself and then practice it outside. It's a beautiful day here in Colorado, it's really quite lovely. And our patients love this exercise too, even though it's simple. It's lovely.

It's kind of easy to remember, it's called Five Senses Noticing. You're going to notice five things, and it starts with five things that you can see, and you give yourself some time and you allow yourselves some time to breathe, get into your body. Four things that you can feel, three things you can hear, two things that you can smell, and finally one thing that you can taste. And if you could do this over five minutes, it really makes a difference. It's not a big complicated practice, it just helps us slow our minds down. And especially if you're in a place of should I or shouldn't I, should I or shouldn't I, I don't know what to do. Gosh, you've called all the people you needed to call, you've done all the consulting and your mind is still in that place where it's the middle of the night and your mind will start racing, you can use an exercise like this to just slow down to the present moment and re-ground yourself, and it can help to regulate the nervous system.

All right, so our yearning for orientation, we start to get lost in the how and the why of things. We focus on the past or future and worry about it being just so. Another thing that comes to mind is if you've ever planned a wedding, and the wedding day is there and you've been so in the planning of it that you ... and then getting through it and all the things to have to happen, it might have felt like, I don't even remember the actual wedding. Oh, my mind was so preoccupied with the mindlessness of the planning of the way that it should be, that it was hard to slow down and even experience the actual thing. And so the way out is to stop, focus on the here and now, slow down. COVID gift, slowing down, being at home, not having so many distractions, what comes up for you. Are you where you want to be on your life's journey?

Then the yearning for meaning and self direction, we want to know, am I going in a right way. And we start to get off course when we pursue wants and shoulds, and get into self righteous gratification like getting the stuff for example, or getting the degrees or the credits after our name or the, now we're the member of the country club. Our focus becomes an acquisition and following the rules of social behavior rather than our actual selves, and it's similar to what happens in the trap of aloneness. We start to feel an emptiness, like did I really do what I wanted to do, or did I just do the things that I thought would look really good to other people. The process towards out of that trap is to focus on what you want to choose to do in this world, is meaningful for you, that makes your heart sing, that allows you to do it no matter what the pain of it might be.

I listen to some pretty sad stories, some pretty awful things. As a person who's been in the counseling profession for many years, I've heard some stuff that's just made my heart break. I still keep doing what I'm doing even though I listen to those awful stories because it's meaningful and valuable to me. My sister who's an attorney doesn't understand. She's like, "Why in the world, you go to work all day, you hear sad stories and then you read those, that Oprah's Book Club stuff. Why would you do that?"

It's because that's who I am, that I like to get into the meaningful human drama of things. And that maybe not be you, but there are some things that we just do because we do them and that's who we are, and that's actually satisfying. It's not actually all the time happy stuff, but it's satisfying and it feels good. It gives us a greater meaning and purpose, and that's values, and working with your loved ones to identify what those are for them. And a lot of them, they've been so turned around on the bus for so long, they don't have a sense of what that is. So we help them with that through assessments, through exploring, let's talk about it.

What we often find is that what they are most in pain about or what somebody's talking about that's really getting to them or hurting, on the other side of that is what they value. That's a clue to what ... Something that you heard about is usually a clue to what you value because we don't hurt about things we don't care about, we hurt about things we care about. In our yearning for meaning and self direction, we start to pursue things that are shoulds or wants or what other people tell us to do, and not what feels right in ourselves. We focus on following the rules and getting the straight As and the acquisition of degrees or goals or metals, which doesn't really fix the thing that might be what we want our life to be about.

So the way out is to start doing things that are more self directed, things that are more in line with our values, rather than practicing the acquisition of things that we don't want, or just in the case of an eating disorder, eliminating the things that we don't want to have, avoiding the things that we don't want to have. And here's some materials that you can look at later. There's Values cards and writing assignments, there's a Valued Living questionnaire you can work through yourself so you can start to give yourself some more clarity. I highly recommend these resources.

And then finally to wrap it up, the yearning for competence. So we've figured out the direction that we want to go and where we are in a journey, and we also yearn to feel like we have some mastery over ourselves and what we do. But what goes wrong is then we get off course by doing external achievement kind of things, we work, work, work, work, work or we put things off and procrastinate in an attempt to avoid certain things. And the focus might become more about being perfect than the act of doing of itself, or avoiding not doing ... not being perfect.

So the one thing that happens I've noticed with eating disorders is that I give the metaphor of the clean room. Some of them, if they can't have their room perfectly clean, they don't clean it at all. It becomes like a complete sty because they're so energetically exhausted that they can't make it perfect so they don't do anything at all, and that's not satisfying, either. We want to look for some middle ground on that. How do we do that? We just start to take action. It doesn't have to be this one giant step that reaches perfection, but building on larger and larger habits towards the values that we want with behavioral commitments.

A way to do this is through some smart goals, defining a goal that is specific, measurable, attainable, relevant and time based. And as we get in the trap of competence through focusing on perfection and being overdriven towards the goal or not doing anything at all, we get into kind of a numb state where we're checked out. And the way out of that is to just start making steps in the right direction no matter how small that they are. They don't have to be perfect.

So I'm going to move forward to some of our more resources because there's lots to learn about ACT, and there are plenty of videos on YouTube, too. You can go to the for some resources and more publications on it. This book, A Liberated Mind that came out last year is really good, and it's written for the public, it's not a academic book. We're cited in it, our founder Rick Bishop was cited in it, and he talks about the work we've done at Eating Recovery Center with using Acceptance and Commitment Therapy, and some references for you here. Okay, so I'm going to stop sharing. Thank you all for your time and listening, and we'll see where we are with questions and discussion.

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