Acceptance and Commitment Therapy in Addressing Anorexia Nervosa: A Case Study

Abstract

Acceptance and Commitment Therapy (ACT) is a third-wave behavioral therapy approach that aims to increase psychological flexibility by helping individuals accept distressing thoughts and emotions rather than attempting to control or eliminate them, while engaging in value-consistent behaviors. Anorexia nervosa is a severe eating disorder characterized by rigid cognitive patterns related to weight control, body image distortion, and eating behaviors. This case study aims to examine the effectiveness of ACT on psychological flexibility, body acceptance, eating-related distress, and engagement in value-driven behaviors in a client diagnosed with anorexia nervosa, through the systematic implementation of ACT’s six core processes: contact with the present moment, acceptance, cognitive defusion, self-as-context, values, and committed action. The Psychological Flexibility Scale was administered before and after the intervention to assess therapeutic outcomes. The client’s life history, eating behaviors, triggering factors, and psychosocial context were systematically analyzed. Throughout therapy, the client was supported in accepting distressing internal experiences rather than struggling with them and in taking actions aligned with personal values. The findings indicate that ACT contributed to improvements in psychological flexibility, body acceptance, and the management of eating disorder–related symptoms, as well as to the development of a more value-oriented lifestyle. This case study points to the possibility that ACT may represent a potentially supportive approach in the treatment of anorexia nervosa and indicates the need for further studies conducted with larger samples.

Keywords

• Acceptance and Commitment Therapy
• Anorexia Nervosa
• Case Study

Project Number

YOK

References

1. Angel, M. J. (2021). Efficacy of acceptance and commitment training (ACT) in a telehealth format to treat individuals with an eating disorder (Master’s thesis). Northern Michigan University.
2. Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724–731. https://doi.org/10.1001/archgenpsychiatry.2011.74
3. Babaee Heydarabadi, M., Ghamari, M., & Hossenian, S. (2022). The effectiveness of family-based therapy on body image and identity styles of female adolescents with anorexia nervosa. Journal of Psychological Studies, 17(4), 33–55. https://doi.org/10.22051/psy.2022.36743.2476
4. Battle, M. (2024). A Preliminary Investigation of Defusion and Self As Context Act Processes in Persons With Traumatic Experience (Master's thesis). Southern Illinois University at Carbondale.
5. Berman, M. I., Boutelle, K. N., & Crow, S. J. (2009). A case series investigating acceptance and commitment therapy as a treatment for previously treated, unremitted patients with anorexia nervosa. European Eating Disorders Review, 17(6), 426–434. https://doi.org/10.1002/erv.962
6. Carvalho, S. A., Palmeira, L., Coutinho, M., Barbosa, R., & Trindade, I. (2022). Self-as-context and depressive symptoms in the general population: A further analysis of the self experiences questionnaire. Current Psychology, 41(12), 8897–8907. https://doi.org/10.1007/s12144-021-01383-6
7. Deacon, B. J., Fawzy, T. I., Lickel, J. J., & Wolitzky-Taylor, K. B. (2011). Cognitive defusion versus cognitive restructuring in the treatment of negative self-referential thoughts: An investigation of process and outcome. Journal of Cognitive Psychotherapy, 25(3), 218–232. https://doi.org/10.1891/0889-8391.25.3.218
8. Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. The Guilford Press.

9. Fichter, M. M., & Quadflieg, N. (2016). Mortality in eating disorders: Results of a large prospective clinical longitudinal study. International Journal of Eating Disorders, 49(4), 391–401. https://doi.org/10.1002/eat.22501
10. Francis, A. W., Dawson, D. L., & Golijani-Moghaddam, N. (2016). The development and validation of the Comprehensive Assessment of Acceptance and Commitment Therapy processes (CompACT). Journal of Contextual Behavioral Science, 5(3), 134–145. https://doi.org/10.1016/j.jcbs.2016.05.003
11. Godbee, M., & Kangas, M. (2020). The relationship between flexible perspective taking and emotional well-being: A systematic review of the “self-as-context” component of acceptance and commitment therapy. Behavior Therapy, 51(6), 917-932. https://doi.org/10.1016/j.beth.2019.12.010
12. Graham, C. D., Gouick, J., Krahé, C., & Gillanders, D. (2016). A systematic review of the use of acceptance and commitment therapy (ACT) in chronic disease and long-term conditions. Clinical Psychology Review, 46, 46–58. https://doi.org/10.1016/j.cpr.2016.04.009
13. Griffiths, C., Williamson, H., Zucchelli, F., Paraskeva, N., & Moss, T. (2018). A Systematic Review of the Effectiveness of Acceptance and Commitment Therapy (ACT) for Body Image Dissatisfaction and Weight Self-Stigma in Adults. Journal of contemporary psychotherapy, 48(4), 189–204. https://doi.org/10.1007/s10879-018-9384-0
14. Hartmann, A. S., Thomas, J. J., Greenberg, J. L., Rosenfield, E. H., & Wilhelm, S. (2015). Accept, distract, or reframe? An exploratory experimental comparison of strategies for coping with intrusive body image thoughts in anorexia nervosa and body dysmorphic disorder. Psychiatry research, 225(3), 643–650. https://doi.org/10.1016/j.psychres.2014.11.031
15. Hayes, S. C. (2005). Stability and change in cognitive behavior therapy: Considering the implications of ACT and RFT. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23(2), 131–151. https://doi.org/10.1007/s10942-005-0007-9
16. Hayes, S. C. (Ed.). (2016). The act in context: The canonical papers of Steven C. Hayes. Routledge/Taylor & Francis Group.
17. Hayes, S. C., & King, G. A. (2024). Acceptance and commitment therapy: What the history of ACT and the first 1,000 randomized controlled trials reveal. Journal of Contextual Behavioral Science, 100809. https://doi.org/10.1016/j.jcbs.2024.100809
18. Hayes, S. C., & Pankey, J. (2002). Experiential avoidance, cognitive fusion, and an ACT approach to anorexia nervosa. Cognitive and Behavioral Practice, 9(3), 243–247. https://doi.org/10.1016/S1077-7229(02)80055-4
19. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press.
20. Hayes, S.C., Pierson, H. (2005). Acceptance and Commitment Therapy. In: Freeman, A., Felgoise, S.H., Nezu, C.M., Nezu, A.M., Reinecke, M.A. (eds) Encyclopedia of Cognitive Behavior Therapy. Springer, Boston, MA. https://doi.org/10.1007/0-306-48581-8_1
21. Juarascio, A., Shaw, J., Forman, E., Timko, C. A., Herbert, J., Butryn, M., Bunnell, D., Matteucci, A., & Lowe, M. (2013). Acceptance and commitment therapy as a novel treatment for eating disorders: an initial test of efficacy and mediation. Behavior modification, 37(4), 459–489. https://doi.org/10.1177/0145445513478633
22. Kabat-Zinn, J. (2018). Meditation is not what you think: Mindfulness and why it is so important. Hachette UK.
23. Kaidesoja, M., Cooper, Z., & Fordham, B. (2023). Cognitive behavioral therapy for eating disorders: A map of the systematic review evidence base. International Journal of Eating Disorders, 56(2), 295–313. https://doi.org/10.1002/eat.23831
24. Karakuş, B., Kesgin, G., & Karaaziz, M. (2023). A Review on Focused Acceptance and Commitment Therapy (F-ACT). ISPEC International Journal of Social Sciences & Humanities, 7(3), 624–634. https://doi.org/10.5281/zenodo.8358604
25. Karakuş, S., & Akbay, S. E. (2020). Psychological Flexibility Scale: Adaptation, Validity, and Reliability Study. Mersin University Journal of the Faculty of Education, 16(1), 32–43. https://doi.org/10.17860/mersinefd.665406
26. Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., & Bischoff-Grethe, A. (2013). Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa. Trends in neurosciences, 36(2), 110–120. https://doi.org/10.1016/j.tins.2013.01.003
27. Kirchberg, M. C., Pinson, C., & Frank, G. K. W. (2024). Pharmacotherapeutic strategies for the treatment of anorexia nervosa - novel targets to break a vicious cycle. Expert opinion on pharmacotherapy, 25(17), 2253–2265. https://doi.org/10.1080/14656566.2024.2424316
28. Kul, A., & Türk, F. (2020). A Review Study on Acceptance and Commitment Therapy (ACT). OPUS International Journal of Society Researches, 16(October 29 Special Issue), 3773–3805. https://doi.org/10.26466/opus.741907
29. Lock, J., & Le Grange, D. (2025). Treatment manual for anorexia nervosa: A family-based approach. Guilford publications.
30. Martinelli, M. K., Schreyer, C. C., & Guarda, A. S. (2024). Comparing hospitalized adult patients with chronic anorexia nervosa with versus without prior hospitalizations. Journal of Eating Disorders, 12(1), 132. https://doi.org/10.1186/s40337-024-01092-y
31. McHugh, L., & Stapleton, A. (2023). Self-as-context. In M. P. Twohig, M. E. Levin, & J. M. Petersen (Eds.), The Oxford handbook of acceptance and commitment therapy (pp. 249–270). Oxford University Press.
32. McLoughlin, S., & Roche, B. T. (2023). ACT: A process-based therapy in search of a process. Behavior Therapy, 54(6), 939-955. https://doi.org/10.1016/j.beth.2022.07.010
33. Mulkerrin, Ú., Bamford, B., & Serpell, L. (2016). How well does Anorexia Nervosa fit with personal values? An exploratory study. Journal of eating disorders, 4, 20. https://doi.org/10.1186/s40337-016-0109-z
34. Onnink, C. M., Konstantinidou, Y., Moskovich, A. A., Karekla, M. K., & Merwin, R. M. (2022). Acceptance and Commitment Therapy (ACT) for eating disorders: A systematic review of intervention studies and call to action. Journal of Contextual Behavioral Science, 26, 11–28. https://doi.org/10.1016/j.jcbs.2022.08.005
35. Parling, T., Cernvall, M., Ramklint, M., Holmgren, S., & Ghaderi, A. (2016). A randomised trial of Acceptance and Commitment Therapy for Anorexia Nervosa after daycare treatment, including five-year follow-up. BMC psychiatry, 16, 272. https://doi.org/10.1186/s12888-016-0975-6
36. Ruiz, F. J., Gil-Luciano, B., & Segura-Vargas, M. A. (2023). Cognitive defusion. In F. J. Ruiz (Ed.), The Oxford Handbook of Acceptance and Commitment Therapy (pp. 206–221). Oxford University Press.
37. Sahdra, B. K., King, G., Payne, J. S., Ruiz, F. J., Ali Kolahdouzan, S., Ciarrochi, J., & Hayes, S. C. (2024). Why Research From Lower- and Middle-Income Countries Matters to Evidence-Based Intervention: A State of the Science Review of ACT Research as an Example. Behavior therapy, 55(6), 1348–1363. https://doi.org/10.1016/j.beth.2024.06.003
38. Sala, M., Levinson, C. A., Kober, H., & Roos, C. R. (2023). A Pilot Open Trial of a Digital Mindfulness-Based Intervention for Anorexia Nervosa. Behavior therapy, 54(4), 637–651. https://doi.org/10.1016/j.beth.2023.01.003
39. Scardera, S., Sacco, S., Di Sante, J., & Booij, L. (2021). Body image-related cognitive fusion and disordered eating: the role of self-compassion and sad mood. Eating and weight disorders : EWD, 26(2), 483–490. https://doi.org/10.1007/s40519-020-00868-w
40. Stoddard, J. A., & Afari, N. (2014). The big book of ACT metaphors: A practitioner’s guide to experiential exercises and metaphors in acceptance and commitment therapy. New Harbinger Publications.
41. Waltz, T. J., & Hayes, S. C. (2010). Acceptance and commitment therapy. In N. Kazantzis, M. A. Reinecke, & A. Freeman (Eds.), Cognitive and behavioral theories in clinical practice (pp. 148–192). The Guilford Press.
42. Westmoreland, P., Yager, J., Treem, J., & Mehler, P. S. (2024). Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa. Focus (American Psychiatric Publishing), 22(3), 344–349. https://doi.org/10.1176/appi.focus.20230035
43. Wilson, K. G., & Roberts, M. (2002). Core principles in Acceptance and Commitment Therapy: An application to anorexia. Cognitive and Behavioral Practice, 9(3), 237–243. https://doi.org/10.1016/S1077-7229(02)80054-2
44. Yetiz, G., & Çetinkaya Yıldız, E. (2023). The Effect of an Acceptance and Commitment Therapy-Based Psychoeducation Program on University Students’ Self-Compassion Levels During the Pandemic Period. Ahi Evran University Journal of Kırşehir Faculty of Education, 24(3), 1651–1680. https://doi.org/10.29299/kefad.1216722
45. Zipfel, S., Giel, K. E., Bulik, C. M., Hay, P., & Schmidt, U. (2015). Anorexia nervosa: aetiology, assessment, and treatment. The lancet. Psychiatry, 2(12), 1099–1111. https://doi.org/10.1016/S2215-0366(15)00356-9