When it comes to solving problems with eating and body image, a one-size-fits-all approach doesn’t work. Different things work for different people. While cognitive behavioral therapy (CBT) is backed by research as being the most effective treatment for eating issues, there are a host of other psychotherapeutic models, mind-body approaches, and expressive arts modalities that can be powerful in bringing about healing.
We are all unique individuals, so it makes sense that different approaches, and different combinations of approaches, are likely to be helpful for different people. Also, different models use different language for describing similar concepts, and different language makes more—or less—sense to different people.
I think of human beings as like tables with four legs: mind, body, emotions, and spirit. All four legs must be sturdy for the table to be balanced. Eating, food, and body-image problems involve the mind, the body, and emotions, and I believe they are, fundamentally, a malady of the spirit, for they obscure one’s awareness of their innate worth, value, and goodness. Healing such problems means repairing all four legs. Over the next few months, I’ll talk about various therapeutic approaches for dealing with these legs as they relate to eating issues, and how they can be mixed and matched to suit individuals.
Addressing such issues must include focusing on the mind, for which CBT is great. Recognizing core beliefs and cognitive distortions is imperative. However, in my work with people, and talking to colleagues about their work, I find that CBT alone can run the risk of causing a sense of invalidation—“I’m already not good enough, and now you’re telling me my thoughts are wrong!” This is where mindfulness practices, dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), ego-state therapies such as Internal Family Systems, body-oriented therapies, and mind-body practices such as yoga and yoga therapy can be valuable. A premise of all of these is that it’s important to observe and accept our thoughts without judging or trying to change them.
Mindfulness is thought to have originated in ancient Buddhist or Hindu practices as a form of meditation and a means of being fully present in each moment, the idea being that the present moment is where we truly live. Thoughts about the past and future, even five minutes ago or from now, take us out of the moment and mire us in anxiety about what will happen, or shame about what did, which in turn can drive us to resort to unhealthy strategies to avoid feeling.
Mindfulness practice involves nonjudgment—that is, noticing our experience of the present moment (what we see, hear, touch, and taste as well as what we’re thinking and feeling), without any evaluation as to it being good, bad, right, or wrong. Nonjudgment’s cousin is acceptance—not resisting or denying anything that exists, no matter how unpleasant. Acceptance is important because when we refuse to accept something and insist on judging it, our energy is bound to that thing. We obsess about it and are upset by it, sometimes so much so that we again resort to unhealthy strategies to feel better. When it comes to eating and food issues, accepting our bodies as they are, and accepting ourselves no matter what or how much we’ve eaten, is a huge challenge.
Acceptance is the cornerstone of two effective therapy models: DBT and ACT. In DBT, the premise is that with regard to mental and emotional struggles, there is a fundamental dialectic, or two seemingly contradictory things that are simultaneously true: acceptance and change. DBT holds that we cannot change something until we first accept it—that trying to change something without first accepting it without judgment is futile.
With eating problems, we must first accept the reality of the problem before we can set about to change it. Once accepted, we can learn skills for managing the painful emotional states that can drive conflicted relationships with food, and to use them instead of acting on urges to overeat, undereat, exercise compulsively, or induce vomiting after eating. The first of the four main DBT skills is core mindfulness. The others are emotion regulation, distress tolerance, and interpersonal effectiveness.
I think of ACT as the Alcoholics Anonymous “serenity prayer” (God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and wisdom to know the difference”) expanded into a therapeutic approach. ACT teaches us how to mindfully observe and then accept our thoughts and emotions, but not to act on them; rather, to make a decision on the course of action to take based on our values. So, for example, if someone were to feel hurt or upset about something and then have strong urges to make an excuse to stay home alone and binge and vomit, ACT would direct them to feel the hurt, notice the thoughts and urges, but because they value honesty and friendships, keep their plans with their friends and perhaps talk to them about their struggles.
ACT and DBT principles can be combined with one another and with CBT. Next time, I’ll talk about some other approaches and how they also can be used with mindfulness practice, ACT, and DBT.
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