1 copyright weight escape; ciarrochi & bailey, 2013€¦ · research suggests a clear link...

Copyright Weight Escape; Ciarrochi & Bailey, 2013

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Table of contents Acceptance-based approaches to promoting health .........................................................................3 The six ACT processes and psychological flexibility .........................................................................5 Relating the ACT processes to Health .................................................................................................. 10 Putting ACT into practice: The O.W.L. Skills ...................................................................................... 12 ACT and the transtheoretical model of behavior change ............................................................. 37 ACT Evidence part 1: ACT improves diet and physical activity ................................................. 42 ACT evidence part II: ACT is beneficial for other health-related conditions ........................ 44 References ...................................................................................................................................................... 48


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Acceptance-Based Approaches to Promoting Health Standard behavioural weight-loss programs include sessions on overeating in

response to emotions and thoughts. Participants are typically taught to control or alter

these thoughts through cognitive restructuring, distraction, and refocusing [1] . However,

a recent experimental study suggests that, amongst those most susceptible to food

cravings, control strategies may make it more difficult to cope with food cravings and

lead to consumption of craved foods. In contrast, acceptance-based strategies may

reduce cravings[2] .

The paradoxical effects of control have now been highlighted in numerous studies

(for review, see [3, 4]). For example, participants who are asked to supress a thought

typically show an increase in the frequency of that thought [5]. Similarly, suppressing a

mood can lead to an increase in intensity of that mood [6, 7]. Suppression has been

found to be associated with heightened pain experience[8], anxiety [9], problems with

sleep quality[10], and increases in the reinforcing effect of alcohol [11].

Acceptance-based strategies form the basis of a new generation of approaches

that include Acceptance and Commitment Therapy and Mindfulness-based Cognitive

Therapy [4, 12, 13]. These approaches do not seek to alter private experiences such as

cravings or self-doubt. Rather, they promote the mindful acceptance of thoughts and

feelings in the service of valued goals.

We will be using principles of Acceptance and Commitment Therapy (ACT) to inform

the acceptance component of the intervention. ACT currently has substantial empirical

support, with over 62 randomized control trials attesting to its efficacy:


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http://contextualpsychology.org/ACT_Randomized_Controlled_Trials. Many of these

trials have been conducted in health-related areas and suggest that ACT promotes value-

consistent behaviour amongst those who experience chronic pain [14, 15], and promotes

good diabetes self-management [16]. A more complete review is included below.


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http://contextualpsychology.org/ACT_Randomized_Controlled_Trials

The Six ACT Processes and Psychological Flexibility

ACT targets six core processes that are designed to build psychological flexibility.

Psychological flexibility refers to an individual’s ability to connect with the present

moment fully, as a conscious human being, and to change or persist in behaviour that is

in line with their identified values [17].

Increasing psychological flexibility involves helping clients to disentangle

themselves from the cycle of experiential avoidance and cognitive fusion. This happens

not by challenging or changing thoughts and emotions, but by learning to react more

mindfully to such experiences, so that they no longer seem to be barriers [18]. Clients are

encouraged to shift their energies away from experiential control and towards valued

activity, and to consistently choose to act effectively, even in the presence of difficult

private events. For a detailed and comprehensive account of ACT readers are referred to

Hayes et al. [17].

The ACT treatment model consists of six sub-processes that are organized into a

‘hexaflex’ (see Figure 1). The hexaflex can be divided into two main components. The

first includes acceptance and mindfulness processes (acceptance, defusion, the present

moment, and a transcendent sense of self), and the second reflects commitment and

behavioural change processes (values, committed action, the present moment and a

transcendent sense of self). The ACT practitioner targets these six processes in order to

build psychological flexibility.


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Figure 1: The six core processes targeted by ACT are expected to build

psychological flexibility

The hexaflex illustrates that these processes are all connected and support each

other. There is no correct order for focusing on the processes and not all individuals need

to concentrate extensively on each of the processes [19, 20]. The ultimate goal is to help

people to persist in or change their behaviour, depending on what the situation affords,

in order to move towards what they value.

ACT clinicians use a number of exercises for each process to enhance adoption

and understanding of relevant skills [for more detail see 17, 19]. These include

metaphor, paradox and experiential exercises that aim to undermine the power of


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experiential avoidance and cognitive fusion. A brief description of each process will now

be provided.

Acceptance. The focus of this ACT process is to develop and enhance an

individual’s willingness to have and accept their private experiences. Treatment involves

exploring the futility of emotional control and avoidance, which can often paradoxically

increase an individual’s level of distress and deter them from engaging in purposeful and

vital, value driven behaviour. Instead, individuals are encouraged to accept their private

experiences, when doing so helps them engage in valued behaviour.

Defusion is a process that involves weakening the language processes that

promote fusion [17, 19]. People learn to see thoughts for what they are and not what

they say they are [17], for example, symbols of one’s experience and not actual

descriptive ‘realities’. Defusion exercises help people to notice their language processes

as they unfold and to watch the thoughts come and go, almost like a neutral observer.

Defusion thus involves a radical shift in context, where thoughts are observed events,

rather than literal truths that must dictate behaviour.

Getting in contact with the present moment. This ACT process is often equated to

mindfulness. Clients are taught to build their awareness of their private experiences and

be fully open to what is happening in the present moment. In the mindful state, thoughts

are expected to be experienced as what they are, events that come and go, rather than

what they often seem to be, truths that bind or actual barriers. For example, a self-critical

thought such as “I am useless” can be viewed as a passing event rather than something

that must control behaviour. Mindfulness also connects to the values and commitment

component of ACT, in that it allows the regulation of action that is informed by needs,

feelings, values, and their fit with the current situation [21]. According to Strosahl et al.


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[19] and Hayes et al. [17], the qualities that reflect this process are vitality, spontaneity,

connection, and creativity.

Self-as-context. Clients are taught to build their awareness of their ‘observing self’,

or self-as-context, and work on letting go of their attachment to a conceptualised self (i.e.

I am boring; I am useless). The self-as-context is independent of content: It is the place

where content is observed. No matter how many self-statements we generate about who

we are (“I am a father:” “I am an athlete;” I am not good enough”), there is an “I” that can

observe these self-statements. This ‘I’ is experienced as constant and stable, whilst the

self-evaluations come and go [17]. From the perspective of self-as-context, people come

to realize that they can let go of unhelpful self-evaluations and retain a sense of self [22].

Values. Values refer to the directions in life that individual’s choose which guide

their behaviour. Thus, values are never really achieved or obtained, yet they are always

present every time an individual chooses them [17, 22]. Individuals who are entangled in

fusion and experiential avoidance are more likely to engage in behaviours that are

inconsistent with their values. For example, even though an individual may value a

relationship, they may engage in destructive social behaviour, because they are afraid of

intimacy. People in ACT learn to choose willingness to experience difficult thoughts and

feelings, in order to engage in valued behaviour [19].

Committed Action. Engaging in value-directed behaviour can often produce

difficult experiences such as distress, failure, and fusion. ACT helps people to see that

choosing a valued direction is not a permanent thing. The choice must be made again and

again, for example, after failure. ACT helps prepare people for the difficult feelings and

thoughts that will show up due to their valued striving and to be more willing to “carry”

those feelings and thoughts in order to do what it takes to move in a valued direction.


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The “inflexahex” is another way of looking at the various processes in [23]. Each

“positive” process in ACT has a negative counterpart, as illustrated in Figure 2.

Figure 2: The inflexahex model of suffering and problematic behaviour


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Relating the ACT Processes to Health There is evidence for the intervention components found in ACT [24]. Below, we

discuss the components as they relate to health, and direct you to related research.

Acceptance techniques teach participants to be mindful of unpleasant thoughts and

feelings without attempting to change or avoid them by engaging in ineffective coping

strategies. In the health area, such ineffective strategies include emotional eating,

binging, and impulsive eating. Research suggests a clear link between emotional eating

and higher BMI [25].

Mindfulness and defusion help participants experience their thoughts and feelings

mindfully, as mere products of the mind that do not need to be acted upon. Example

exercises include “urge surfing”, mindfulness of emotions and how they affect eating, etc.

Mindfulness can also be applied to standard dietary interventions, e.g., Mindful self-

monitoring (food intake, exercise, weight).

Fusion, the opposite of defusion, indicates that someone is under the

excessive control of rules. Research suggests that people who follow rigid diet rules are

actually more likely to binge eat and have higher weight[26, 27]. Mindfulness is

antithetical to fusion. It is easier to let an unhelpful rule go when we see it as just some

passing sounds in our head. We now know that when we make mindfulness a habit, we

can expect: Better Handling of negative events, Increased Self control, Better

relationships with others, Reductions in chronic stress, Improved mental performance,

and Better ability to overcome bad habits [28]


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Self-as-context and Self-Compassion. This component helps participants to mindfully

notice their self-criticisms, to acknowledge and accept them as a normal part of being

human, and then to act in a value-consistent way even in the presence of the self-

criticism.

Research suggests that self-compassion is associated with higher genuine motivation to

exercise [29], higher well-being [30], better response to negative life events [31], better

response to failure, and higher motivation to improve ourselves [32].

Values. All acceptance components are in the service of values. This component

helps participants to identify how their eating and physical activity fit with their core

values. Value clarification has been shown to help people manage stressful events,

improve intellectual performance, improve relationships with others, and help people

experience greater openness to life, and reduce weight and waistline [33-37].

Committed action. This component helps participants to focus on their values

during emotionally difficult times, in order to promote persistence in valued living (the

below are standard components in behavioural interventions and will be included in our

intervention).

o Stimulus control –i.e., reengineering the environment to make

healthy choices more likely. See, e.g., Wansink [38]

o Problem solving. Common barriers to healthy diet and exercise

o Assertiveness training. E.g., being able to say “no” when people are

encouraging you to eat more than you want

o Goal setting. See Ottingen and colleagues [39]

o Relapse prevention. Helping people to monitor health-behaviours,

and make early detection if failing to engage in the behaviours


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Putting ACT into practice: The O.W.L. Skills

Sometimes it is useful to reduce the ACT processes to three simpler skills, which

can be remembered by the acronym, O.W.L. These skills involve– Observing, being

Willing and Living Your Way.

Observing

Observing, or mindfulness involves paying attention with curiosity and openness.

To understand the power of mindfulness, we have to take a quick look at the

pervasiveness of mindlessness and suffering. Humans are unique in their ability to be

anywhere but here, in the present moment. Let's do a little experiment to illustrate this

point.

• Take a moment now to think about something in the future that worries you.

• Now think about something in the past that you regret or that still bothers you

• Finally, think about some aspect of yourself that you really dislike

Those three questions brought you into the future, the past, and what we will call

the “basement.” The basement is that metaphorical place you go to criticize yourself. We

all have a basement. For some of us, it is a dark unpleasant place, with a single glaring

light bulb and an uncomfortable chair.

Here is the important thing to notice. When your mind took you to the basement

(self-criticism), where were you? Where was your breath? It was still here, in front of this

book, in the present moment. There was no basement. It was something created by your


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mind. You can say the same thing about the past and the future. We seem to inhabit these

places for much of our lives, and yet we never really inhabit them. We inhabit this

present moment only.

We are said to be “mindless” when we are stuck in the future, the past, or the

basement. Practicing mindfulness exercises can strengthen your observing and

mindfulness skills, the “O” in owl. You can learn to direct your mindful attention to this

present moment, to your food and food environment, to your feelings and thoughts, to

your urges and hunger, and to the things you enjoy and love.

Willingness

We have never met somebody who likes to feel distress. Who wants to feel afraid,

or angry, or sad? Nobody. But here is a thought experiment for you. Imagine that you

decided you were unwilling to ever feel negative feelings. What would happen then?

Would you be able to do anything?

Every important thing we do comes with a risk of distress. To have friendship, you

risk conflict. Tough goals risk failure, dieting risks disappointment, falling in love risks

rejection. The only way to avoid distress entirely is to do nothing important. You must

shrink your life so much that you're no longer acting in the world, that you become cut-

off and unable to find joy.

Unwillingness is a shutting out of life. Willingness is opening up. The more you are

willing to hold distress, the more you're able to do. Other words for willingness might be

“grit”, “distress tolerance”, or “character”. Willingness is going to be essential to

expanding your life so that you can get more of what you and do more of what you care

about and love.


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Listen to your values and act on them

Because our mind can get us stuck in the future, the past, or the basement of self-

criticism, we lose sight of what we care about. We forget that we like exploring, painting,

or playing. We drop enjoyable activities the way a child drops a favourite toy and forgets

about. We become mindless and lost.

The good news is, you can reconnect to what you care about. And your values will

be your greatest source of power and energy. They will focus your mindful attention to a

purpose (Think of the owl hunting with purpose). They will give dignity to your

willingness to experience distress. They will allow you to stay on your path, even when

you encounter barriers and people who tell you can't do something.


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The O.W. L. skills for Vital Living

Observe Stop, Step Back, Observe, Describe Practice directing mindful awareness towards eating, towards world around you, and towards own thoughts and feelings

Willingness

Is it worth the distress? If no, choose another goal If yes, make room for the distress and carry it with you.

Live your values

Choose a value, identify a specific goal Identify benefits and difficulties in achieving goal If difficulty occurs, specify what you will do


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Overview of client challenges and related strategies

OWL process/ACT

process Client challenge Suggested strategies

Observing/ mindfulness

Client seems to have weak awareness of the present moment. Often engages in mindless eating or binging

Observing Techniques How to eat mindfully

Living values/ commitment/ stimulus control

Client environment is not conducive to healthy diet

10 tips for making it easier to choose the healthy

option

Observing/mindfulness Client is struggling with cravings Hunger versus Cravings handouts

Living your values/ committed action/

Client seems unable to act, or persist in action

The five step plan to changing your life

Willingness/ Acceptance

Client engages in emotional eating. Uses food to escape or manage feelings

Diary: spot the food and mood cycles

Observing/Defusion Client seems dominated by unhelpful thoughts or beliefs about diet (e.g., excuses, unhelpful diet rules), or about themselves (self-defeating beliefs, insecurity)

Passengers on the bus worksheet

Live your values Client has unclear values and unclear intrinsic reasons for committing to valued action. Client seems unmotivated.

Values clarification exercise

Observing/self-as-context/self-compassion

Client is hard on self after failure. Client believes the best way to motivate self is through self-criticism.

Letting go of self-esteem, finding self-compassion.


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Observing Techniques

When we are in a mindless state, our thoughts, feelings, cravings, and impulses push us

around. The key point of stepping back is to create a little space between you and your

inner experience. You learn to hold your inner experience in the same way the sky holds

the weather: You hold feelings and thoughts and let them come and go.

You can have a craving and choose to eat or not eat. You can experience fatigue and

choose to exercise or not exercise. You can observe your mind beating yourself up and

telling you that you are not able to do things, while you are in the act of doing something

important.

Stepping back is not about removing feelings and thoughts. It is about carrying feelings

and thoughts, in a way that gives you more choice and freedom.

Here are a few techniques that might help you step back. Find the one that works best for

you.

1) Stop, Step back, Observe, Describe: Stop and step back from your thoughts and

feelings. Observe (notice what is showing up). Describe what you are thinking and

feeling (“I’m having the feeling that....; I’m having the thought that.....).

2) Write it down: Write down your difficult thoughts and feelings. Look at them on a

piece of paper. Carry them with you while you act according to your values. Write them

using funny letters or different colours. Basically, do what you can to look at your

internal content in different ways.

3) Play with the thoughts on your inner computer screen. (Imagine the thought and

change its shape, colour, motion)

4) Mindfulness practice: Use mindfulness to slow yourself down and stop yourself from

reacting to your thoughts and feelings.


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4a. Count your breath. Just focus on your breath and count at each inhale until you

get to ten. Then start again at 1. If you find yourself getting distracted, just gently bring

yourself back to the breath. You will get distracted again and again. They key practice is

in the returning.

4b. Three minute breathing space:

1. Awareness. Bring yourself into the present moment by deliberately adopting an

erect and dignified posture. If possible, close your eyes. Then ask: What is my experience

right now……in thoughts……in feelings……and in bodily sensations?” Acknowledge and

register your experience, even if it is unwanted. Take a non-judgmental stance.

2. Gathering. Then, gently redirect full attention to breathing, to each in breath

and to each outbreath as they follow, one after the other. You might want to count each

breath until you get to 10 and then go back to one and count again.

3. Expanding. Expand the field of your awareness around your breathing, so that it

includes a sense of the body as a whole, your posture, and facial expression

4c. Leaves on the stream. Close your eyes, and imagine a flowing stream. Imagine

leaves floating by on the stream. Now, watch for your thoughts and feelings, and as you

see each, please place it on a leaf and watch it float by.

5) Name your mind. (“Mr. Fred”, or “Ms.. Buzzy”, or “Noise maker.”). Use this name in

sentences (mostly to yourself if you don’t want to be thought crazy). For example, there

goes Ms. Buzzy again, beating me up about my diet.

6) Learn to recognize and label four activities of your mind. 1) Dwelling on the past

(“I should not have eaten that. What is wrong with my motivation?”), 2) worrying about

the future (“what if....”), 3) beating yourself up (“I’m so stupid, I lack all will-power”), 4)

Comparing yourself to others (“She is thinner then me, happier than me, and has no

problems”)


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How to Eat Mindfully

Mindfulness involves paying attention, on purpose, with an attitude of curiosity.

Mindfulness helps you to enjoy your food. You notice so much more about flavours and

smeels when you are paying attention. Mindfulness also helps you to make better food

choices. When you are mindful, you are better able to tell the difference between food

you love and food that you just eat because it is there. Mindfulness puts you in touch with

your own preferences. Finally, Mindfulness practice allows you to make choices based

on what you value. For example, you may choose indulgant food because your primary

objective, at that moment, is merely to enjoy food. Or you may choose vegetables because

you want to serve your health values. You may choose to eat only enough to satisfy your

hunger. Or you may choose to overeat because the food is so good. The point is,

mindfulness practice does not tell you what to do. It gives you more choice.

Here are a few tips for eating mindfuly.

1) Minimize all distractions in your environment. If the T.V. is on, turn it off. If you

have a book or magazine open, close it. You want to able to fully attend to the

food. Now you are ready to place the food in front of you.

2) Bring yourself into the present moment by deliberately adopting an erect and

dignified posture. Then, gently redirect full attention to breathing, to each in-

breath and to each outbreath as they follow, one after the other. You might want

to count each breath until you get to 10 and then go back to one and count again.

Do this for one to three minutes, with your food in front of you.


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3) Scan your body. Notice where you are feeling your hunger sensations? In your

belly, your mouth or maybe your head? Are you actually hungry? Or could this be

an emotion, or a craving you are experiencing rather than hunger?

4) Now, take a portion of your food in either your hands or fork / spoon. Pay

attention to the eating of the food. Be curious:

a. Sight: Look at your food. Notice the different colours, textures and shapes

the food has. Look at its asymmetries.

b. Smell: Raise your food to your nose. Notice the qualities of the smell. Is it a

strong smell or delicate? Where do you feel the smell most in your nostrils?

The front, or in the back of your throat maybe?

c. Touch: place your food on your closed lips gently. What does it feel like? Is

it prickly or textured? Or smooth and slippery?

d. Taste: Finally place your food on your tongue. Notice the sensations.

Where do you taste it most on your tongue? At the back, sides or front?

Describe the taste to yourself. Is it powerful? Subtle? Familiar? Slowly

notice the sensations change as you bite into the food, and eventually

swallow. Is there an aftertaste? Where do you feel it?

Take the next portion. Again revisit every sense slowly as you eat. This time, stop at

points throughout the eating process to reconnect with your body. Where is your hunger

level now? Are you satisfied yet? If so where do you feel this satisfaction in your body?

Do you want to continue eating?

Attend to the rest of your meal in this way, by attending to all your senses mindfully. The

idea is to slow the process of eating right down so you can start to notice the many

distinctions and experiences you have with it.


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10 tips for making it easier to choose the healthy option

Tip 1: Store food in Small containers. People use what they see in front of them, rather

than how hungry they are, to guide how much they eat.

Tip 2: Follow the ‘Half Plate Rule’. Half your plate should be filled with vegetables and

fruit, the other half with protein (e.g.,meat) and starches (e.g., pasta, potato, bread,

and/or rice).

Tip 3. Pre-plate. Put everything you want to eat on a plate before you start eating it. If

you have a whole lot of serving dishes on the table in front of you, you are far more likely

to help yourself to extra servings.

Tip 4. Use smaller plates and bowls to serve your food. It is quite amazing how

effective this is for most people; that serving of food which looks so small on a gigantic

plate, looks far more substantial when you serve it in a small bowl.

Tip 5: Decrease variety of unhealthy foods, increase the variety of healthy foods.

Research suggests the greater the variety of foods in front of us, the more we will eat it.

This is because we tend to grow tired of eating the same thing.

Tip 6: Reduce distraction when eating. Research consistently shows that we eat more

when we are distracted. We tend to eat more in front of the TV, listening to radio,

working on the computer, or reading the paper.


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Tip 7. Watch out for the “more people, more eating” effect. We tend to eat more in

the presence of other people. The more people present, the more we tend to eat.

Tip 8: Reduce access to unhealthy foods. If you see food, you tend to eat it. Put treats

away in a cupboard, and put a bowl of fruit on the table.

Tip 9: Avoid the “desperate zone.” Know when you are likely to be “starving” and have

healthy snacks available.

Tip 10: Rest and work your body. Research suggests that getting plenty of sleep and

exercise helps you to have greater self-discipline and make less impulsive choices.


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Hunger versus Craving

We know, from our own experience, that no matter how determined you are to be

kind to yourself, you will still have times when you are self-critical. Our minds criticize.

That is what they are good at. Here we will talk about how to manage this criticism when

it is directed at our physical appearance.

Think about what your mind says about your body. Are you “too big”? Or perhaps

the “wrong” shape (according to your mind)? Are you “not attractive enough.” Do you

notice your mind criticizing different parts of your body, e.g., your thighs, stomach, chest,

and buttocks. Do you notice how your mind sometimes criticizes bodily sensations, such

as hunger (e.g., “you are being weak”) or fatigue (e.g, “ you should be more alert”). Our

minds have a hundred ways to attack us.

When we view the body as an enemy, we seek to disconnect from it and get as far away

from it as possible. We lose touch with it. We can’t hear it when it says we are hungry,

full, stressed, or tired. We eat sometimes to shut it up, or even to punish it. The war

between mind and body can never be won, for the mind and body are not separate

things. There is only one you.

These following ideas will help you to make peace with your body and discover the

wisdom it offers. You will get in touch with signals of hunger, fullness, and cravings. You

will learn three steps to more mindful and value-consistent eating.

• Step 1: Recognize hunger signals (and distinguish them from craving)

• Step 2: Learn to eat when hungry. Learn to stop eating when comfortably full (but

not too full)

• Step 3: Develop your personalized craving plan and test it out.


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Step 1: Recognize hunger signals and distinguish them from cravings.

Why is it important to distinguish between hunger and cravings? We eventually

have to eat if we are hungry, but we don’t have to eat when we have a craving. So if we

can learn to recognize cravings, we can learn to recognize important choice points. We

can indulge the craving. We can ignore the craving in the service of health values. Or we

can indulge in moderation. The key here is to recognize when we are having cravings and

have a choice.

Hunger is driven by our body’s physical needs. Cravings are usually driven by

environmental or psychological factors, such as the sight of food or stress. The table

below illustrates some of the key differences between hunger and craving.

Hunger versus cravings

Hunger Craving Driven by bodies needs Something in environment triggers it (e.g.,

site of chocolate)

The feeling does not go away if you wait it out

The craving often goes away if you do nothing

The sensations intensify over time The sensations do not intensify

Nothing you do will take away the feeling of hunger except eating

Doing something else will end the craving e.g., engaging in a valued activity

Almost any food will alleviate hunger Only one food will alleviate craving

It is easy to get hunger and craving mixed up. We would recommend you experiment

with hunger so you can learn to clearly recognize it. We are going to suggest that you

delay a meal to experience the feelings of hunger. Please consult with your doctor before


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you do this and make sure it is safe for your circumstances. You might also want to try

this on a day you are not working. Just skip a meal and let yourself feel hunger.

What signals did you notice from your stomach? Did you notice growls, pangs, or empty

feelings? Describe in your own words:

What signals did you notice from your head? These might include fogginess, difficulty

concentrating, headache, agitation, and/or fatigue? Describe in your own word

Step 2: Learn to eat when hungry. Learn to stop eating when comfortably full (but

not too full)

Once you are in better contact with what hunger feels like, you can start to make

finer distinctions about your level of hunger or fullness. Hunger is not the enemy. It is an

important and valid signal from your body.

The hunger scale below will help you to notice different body states. Learn to eat when

you are around 3 on this scale. Listen to your body. Don’t wait until you are completely

famished to eat (or you might, out of desperation, eat something extremely fatty and

unhealthy, or overeat).

Remember that it takes some time for the signal of stomach fullness to reach the satiety

centres in the brain, telling you to stop eating. It is a good idea to stop eating before you

feel full. E.g., if you stop eating at 5, you will probably end up with a 6. It might be best to


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stop eating at around 4. Then you can wait and see what your body tells you. If you are

still hungry after 10 minutes, you might choose to eat some more.

Table: Hunger scale 9 Stuffed, so full it hurts. 8 7 Overfull, need to loosen clothes 6 5 Comfortably full 4 3 Hunger pangs, need to eat something 2 1 Starving, famished, dizzy

Step 3: Develop your personalized craving plan and test it out.

The good news is that cravings, unlike hunger, will pass with time, even if you do not eat

something. Our experience is that cravings last about 10 minutes. Let’s take a moment to

look at your experience.

Next time you have a craving, we would like you to use your O.W.L skills. Specifically:

Observe: What does the craving feel like? How long does it last?

be Willing: Open up to the feelings related to craving. Let yourself have them without

making them go away. Do you feel stressed? Do you feel strong urges to make yourself

feel better by eating? Or are you having the simple desire to enjoy a particular food?

Live your values. Decide whether you want to completely indulge your craving, indulge

just a little, or not indulge at all. Look to your values in this situation.


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Common values might be “enjoying food” and “eating healthily.” Sometimes these values

conflict, sometimes they don’t. Only you can decide.

What can you do when you decide you do not want to give in to the craving? We

recommend that you develop a custom plan to deal with the cravings. Remember,

cravings, unlike hunger, only last a relatively short time.

Here are some tips for developing a craving management plan.

1. Remove or avoid craving triggers. For example, if you crave chocolate and do not

want to eat much of it, you would be well served to remove it from your house.

2. Do something value consistent instead of indulging in the craving. For example,

you might call a friend, listen to music, exercise, or play a game. You can

deliberately choose to engage in valued behaviour and say to yourself, “This is

what I choose to do.”

3. Indulge yourself a little; especially if the craving is something you do for the

pleasure of it and not just to manage distress. Food is not the enemy. Eating can be

a joyful experience.

Take a moment to plan for your craving. Please answer the questions below, or at least

give yourself a few minutes to think about your answers (remember, do not make this

yet another thing to criticize yourself about. If you have read this far and are thinking

about how to manage cravings, you have taken a big step already).

What can I do to remove craving triggers?


27

What valued-actions can I engage in instead of indulging in the craving?

Summary: Our eating habits have been built up over years. We understand that changing

the way we eat and the way we think about our bodies is going to be extremely difficult.

But change is possible! Watch out for your mind and its tricks. It will tell you that you

should be making large amounts of progress. It will tell you that if you don’t see results

immediately, you should give up. Practice listening to your mind and its doubts, and

continue to take steps towards what you value. The steps can be small. If you are patient

and take many small steps, eventually you will travel a great distance. You will be on a

journey of your choosing.


28

The Five - Step Plan to Changing Your Life 1) Identify guiding value. Values are like guiding stars. You set your course by them, but you never actually reach them or permanently realize them. (e.g., being healthy))

2) Set specific and achievable goals that will let you to put your value into play (e.g., eating four servings of vegetables each day) 3) Identify Benefits. Imagine the most positive outcome of achieving your goals (e.g. having more energy, losing weight, improving health and fitness). 4) Identify critical difficulties. Imagine the potential difficulties and obstacles that might stand in the way of you achieving your goals. Internal difficulties (feeling and thoughts such as low motivation, self-doubt, distress, anger, hopelessness, cravings) External difficulties (things outside your skin that might stop you, e.g., cost of gym, time conflicts) 5) Make commitments. I commit to _______________________________________________________ (your goal) Commitment opportunities The following are some opportunities for me to put my commitment into play Example: If I am at a restaurant, I will order steamed vegetables instead of garlic bread If ______________________________, then I will __________________________ If ______________________________, then I will __________________________ If ______________________________, then I will __________________________ If ______________________________, then I will __________________________ Commitment difficulties If _____________________________(difficult internal experience, e.g. feelings) shows up, then I will use my observing skills and make room for the experience. If I am unwilling to have the experience, I will pick a goal that is less difficult for me. If__________________________(external difficulty) comes up, then I will take the following steps to deal with the difficulty (problem solve and write action plan here)


29

Diary: Spot the food and mood cycles Date:_________ Mon Tue Wed Thurs Fri Sat Sun

Time “Food triggers.” Describe aspects of the environment that prompted you to eat.

Food Feelings before eating. What was your mood? Did you feel hungry?

Feelings after eating. Was eating this food consistent with your values (circle one)?

Yes Somewhat No Yes Somewhat No Yes Somewhat No Yes Somewhat No Yes Somewhat No Yes Somewhat No Yes Somewhat No Yes Somewhat No Yes Somewhat No Yes Somewhat No Example triggers. Activities (TV, socializing, reading, entertainment), events (parties, special occasion, friend and family get together), time of day, people (difficult people, people who encourage you to eat), advertisements (commercials, billboards, etc), presence of food (sights, sounds, smells). Example moods: exhausted, unmotivated, angry, sad, anxious, stressed, frustrated, hopeless, pressured, hurt, lonely, embarrassed, shy, guilty, ashamed, insecure, self-hatred Example values: seeking health, seeking physical pleasures, being a good friend, developing and maintaining love, being a supportive parent Observe your feeling and food cycles Willingly have difficult moods and self-doubt and open up to them (instead of seeking to reduce them with food) Live your values. Can you find ways to enjoy food and eat healthily?

Copyright Weight Escape, Ciarrochi & Bailey, 2013 30

Exercise: Passengers on the Bus

Identify the direction you would like to go (your health value) and write it in the space provided. Now identify the “passengers” on your bus—the difficult thoughts, feelings, excuses that, if you listen to them, will guide you off of your valued path. You can carry your passengers and commit to your health values. Your passengers never have to stop you.

Health Value:


Values clarification Exercise: Explore what sort of person you want to be. Then rate how important that area is for you from 0 (not important) to 10 (of the highest importance), and the extent that health is related to that valued area Valued area Example values What sort of person would you like

to be in this area? Importance O to 10

How would health and fitness affect this?

Health and fitness

Engaging in exercise, playing sport, caring for myself, being active, being mobile, engaging in activities that are likely to give me more strength, endurance, flexibility, or energy. Enhancing my appearance, managing stress

Not applicable

Intimate relationships

Caring, supporting, connecting, accepting, being honest, opening up, nurturing, communicating well, helping, loving, asserting, being attentive, being present, listening, having fun, forgiving, being kind

Friendship and other relations

See above

Personal development

Discovering, striving to understand, accomplishing, improving, learning

Work Achieving, contributing, being effective, resolving disputes, having influence, building, creating

Spirituality Connecting with god or the universe, acting consistently with religious beliefs or faith

Community Promoting justice, caring for the weak, helping others, lending a hand, improving the environment

Recreation

Enjoying music, art, and/or drama, listening, playing, creating, adventuring, discovering, collecting, building, enjoying food and drink, exploring, inventing, fixing

Safety, security, and sustenance

Keeping safe from danger (self and others), Providing for self and others


Letting go of self-esteem, finding self-compassion.

Many of us have battled with self-esteem. Maybe we wanted to increase it. Maybe we

wanted to have more self-esteem because we thought it would help us to take on a

challenging task.

The problem with pursuing self-esteem is that anytime we do something hard we are

likely to experience self-doubt. This is the way the mind works. It is critical. It finds

reasons to doubt the self. Battling self-esteem can therefore end up being a battle

against your own mind.

To illustrate this point, say the following sentences to yourself and notice what your

mind does.

I am fabulous

I am perfect

I am wonderful

What happened? For most people, their mind rejects at least one of these statements.

Even if your mind did not reject it now, it would probably reject it in different

circumstances. For example, imagine yourself under pressure, doing something that

pushes you to the limit, or perhaps interacting with someone who questions your value.

What would happen then? It is likely your mind would through some self-doubting

thoughts your way.

Copyright Weight Escape, Ciarrochi & Bailey, 2013

You are the container, not the content. The good news is, self-esteem is just a passing

evaluation anyway. It is not anything we need to fight for or against. Self-evaluations are

like the weather. Rain and wind come and go. You are like the sky. You hold all of this

weather.

Self-compassion

1) Observing. This involves noticing what self-judgments and criticisms are showing

up for you during difficult times. Noticing when and how you beat yourself up. Write

down some common situations where you beat yourself up.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

2) Willingness. This involves opening up to self-criticism, letting your inner critic

scream or shout or whatever it does. It means recognizing that your inner critic is

always going to be there, and will be especially loud when you are having a difficult

time. Willingness means making room for self-criticism.

Lets get in touch with our inner critic. Describe your inner critic below If you have

more than one inner critic, as most of us do, describe them. Here are a few things to

think about when describing your inner critic.

Get to know your inner critic:

• What does it sound like (screaming, shrill, angry, screechy, cold)?


• Does it look a certain way, does it have a gender?

• What does it say?

• If you gave the critic a name, what would you name it

• When is your inner critic most likely to show up

3) Live your values. The last part of self-compassion involves living a particular value.

You might call it “kindness towards yourself” or “self-care.” What values do you have

related to compassion? Put them in your own words. These values have to do with the

way you behave towards yourself


ACT and the Transtheoretical Model of Behavior Change

The transtheoretical model assesses people’s readiness to act on a new health

behaviour [40]. It is sometimes connected to terms like “motivational interviewing” or

“the stages of change model.” At present, there is not strong evidence that it, by itself,

leads to sustained weight loss[41]. However, we believe the stages of change framework

may be useful when combined with ACT principles (especially concerning values and

commitment). It can help focus the practitioner on what most needs to be done with a

client. For example, a client with a BMI of 35 might think they need to change nothing

(pre-contemplation) or might have just started engaging in health promoting behaviour

(action stage). The focus of the intervention for these two clients could be quite

different, as is described below.

The five stages of change are as follows

1. Pre-contemplation stage. Change is not seriously considered.

2. Contemplative stage. Change is considered but no active steps being taken.

3. Determination stage. Determine to take action. (e.g. buy walking shoes, join a

gym or discover a local swimming pool), but we take no action.

4. Action stage. Then action is initiated. We walk regularly; go to that gym, reduce

calories.

5. Maintenance stage. The action is maintained over time. Relapse is anticipated,

barriers are overcome

If you wish to combine the stages of change with ACT, we would recommend a two-

step process.

1) Assess readiness to change (see below).


2) Tailor your ACT intervention for the stage of change. At lower levels of readiness

for change, place relatively heavier emphasis on value clarification and

mindfulness exercises that help people become aware of their current life and

how it might be improved.

Assessing readiness to change.

There are a number of ways to assess stages of change. One quick way to do it is

just to have clients rate readiness and confidence in change on a 10 point scale[42].

1) What is the desired change?

2) How important is it for you to make this change? 0 not important; 10

crucially important

3) How confident are you that you can make the change. 0= no confidence; 10

= completely confidence.

If motivation is high but confidence is low, this might signal the need to do some

work on acceptance, defusion, and or self-compassion (see below). That is, you may

need to emphasise the O and W parts of O.W.L.

If motivation is low, this might signal the need to do some awareness building

(mindfulness; psycho-education on problems of excessive weight or unhealthy

behaviour) and values clarification work. That is, you may need to emphasise the ‘O’ and

‘L’ components of ‘O.W.L’.


The are other, more categorical ways to assess stage of change and these too

might be useful[43, 44] . Below is an example template of how you might assign stage of

change to any health behaviour


Worksheet for Assigning Stage of Change for Health Behaviour

What is the Health behaviour _____________________ __________________________

(e.g., eating a certain amount of vegetables; consuming a certain amount of

calories; exercising a specific amount; limiting high energy dense food consumption;

engaging in specific health-promoting behaviour)

How to use the table: If you answer both questions “yes”, then you have identified the

stage. If you answer the question no, move down one row and ask the next question.

Keep going until you have identified the state

Key questions Stage of Change Emphasize these ACT processes

1. Currently does not do the behaviour regularly? 2. Does not plan to do it in the next 6 months?

Pre-contemplation stage

1. Currently does not do the behaviour regularly? 2. Does plan to do it in the next 6 months?

Contemplation stage

1. Currently does not do the behaviour regularly? 2. Does plan to do it in the next 30 days?

Determination stage

1) Currently does the behaviour regularly? 2) Has not done the behaviour in the past 6 months?

Action


1) Currently does do the behaviour regularly 2) Has been doing it for the past six months

Maintenance Stage

Here are four questions that focus on exercise and allow you to identify the stage of

change from the above table. This are taken from Parker and Colleagues[44]

These next questions will ask you about physical activity in your life…

REGULAR Physical Activity is any regular or planned activity e.g., brisk walking,

jogging, bicycling, swimming, dancing, tennis etc., performed to increase physical

fitness and/or health. Such activity should be performed 3 or more times per week,

should last for 20 minutes or more each time and be performed at a level that

increases your breathing rate, increases your heart rate or causes you to break a

sweat. According to this description, do you:

1. Currently do regular physical activity or exercise

2. Intend to do regular physical activity or exercise in the next 6 months

3. Intend to do regular physical activity or exercise in the next 30 days

4. Have you been doing regular physical activity or exercise for the past 6 months


ACT Evidence Part 1: ACT Improves Diet and Physical Activity

1) Lillis et al. (2009) randomly assigned 84 overweight participants who had lost

weight within the past 2 years to a wait-list or a 1 day ACT workshop targeting obesity-

related stigma [45]. AT 3-month follow-up, Act participants had lost an additional 1.6%

of their body weight, whereas the control group gained .3%.

2) Tapper et al. (2009) randomly assigned 62 women who were attempting to lose

weight to attend four 2-hour act workshops or a control condition. At 6 months,

workshop participants engaged in significantly more physical activity than control

participants. There was a trend for the ACT group to lose more weight (1.35 kg)[46].

The participants who said they applied the principles in the workshop, compared to

those who said they never applied them, showed a significant decrease of 2.3 kg.

Neither the Lillis or Tapper study incorporated specific-weight loss techniques. Both

were designed to complement the weight loss activity the participant was already

engaged in.

3) Weineland et al examined the role of ACT in preventing weight regain amongst

bariatric surgery patients [47]. The trial was an RCT (n=39) with an ACT/internet

condition (two face to face + internet) and a treatment as usual condition. Participants

in the ACT condition significantly improved on eating disordered behaviours (e.g.,

reduced emotional eating), body dissatisfaction, and quality of life. This paper provides

a nice model of a 6 week internet-based ACT program

4) Neimeier et al (2012) examined the effect of an Acceptance-Based Behavioural

intervention on weight loss amongst those who have difficulties with internal

disinhibition (eating in response to emotions and thoughts) [48] . 21 overweight and


obese adults started the trial, with 86% completing the six-month program and a three-

month follow-up. Participants lost an average of 12 kg after six months of treatment and

12.1 kg at 3-month follow up, thus exceeding the weight lost typical seen in behavioural

treatment programs (8kg).

5) Daubenmier et al. (2011) examined the benefit of a mindfulness-based stress

reduction intervention on metabolic syndrome and stress-related eating [49]. 47

overweight/obese participants were assigned to a 4-month intervention or waitlist

group. Treatment participants improved in mindfulness and anxiety and reduced

external-based eating. The obese subgroup showed significant reductions in cortisol

awakening response (CAR) and maintained body weight in the treatment condition,

while the obese control participants had stable CAR and gained weight. Improvements

in mindfulness, chronic stress, and CAR were associated with reductions in abdominal

fat.

6) Juarascio, et al., Inside a larger RCT of ACT versus CT, subanalysis (N = 55) shows

that ACT produced greater reductions in eating pathology, and greater increases in

global functioning [50].

7) Butryn, conducted an RCT (N = 54) comparing 4 hrs of education vs ACT for

promoting physical activity [51]. ACT participants exercised more on objective measure.

8) Goodwin, et al. conducted a Pilot study examining the initial effectiveness of a

brief Acceptance-Based Behaviour therapy for modifying diet and physical activity

among cardiac patients[52] . Approximately 90% of cardiac events are attributable to a

small number of modifiable behavioural risk factors that, if changed, can greatly

decrease morbidity and mortality. However, few at-risk individuals make recommended

behavioural changes, including those who receive formal interventions designed to

facilitate healthy behaviour. Given evidence for the potential of specific psychological


factors inherent in acceptance-based behaviour therapy (ABBT; that is, intolerance of

discomfort, mindfulness, and values clarity) to impact health behaviour change, the

authors evaluated the feasibility and initial effectiveness of an ABBT pilot program

designed to increase adherence to behavioural recommendations among cardiac

patients. Participants (N = 16) were enrolled in four, 90-min group sessions focused on

developing mindfulness and distress tolerance skills, and strengthening commitment to

health-related behaviour change. Participants reported high treatment satisfaction and

comprehension and made positive changes in diet and physical activity. This was the

first evaluation of an ABBT program aimed at increasing heart-healthy behaviours

among cardiac patients

9) Pearson, et al. conducted A pilot study of Acceptance and Commitment Therapy

(ACT) as a workshop intervention for body dissatisfaction and disordered eating

attitudes. Cognitive and Behavioural Practice[53]. RCT (N = 73) showing that ACT helps

with body dissatisfaction and disordered eating attitudes.

ACT Evidence Part II: ACT is Beneficial for Other Health-

Related Conditions

1) Dahl, et al. conducted a small (N = 19) RCT showing that a 4 hour ACT

intervention reduced sick day usage by 91% over the next six months compared to

treatment as usual in a group of chronic pain patients at risk for going on to permanent

disability [14]. .


2) Gifford, et al. conducted an RCT (N = 76) comparing ACT to nicotine replacement

therapy (NRT) as a method of smoking cessation[54]. Quit rates were similar at post but

at a one-year follow-up the two groups differed significantly. The ACT group had

maintained their gains (35% quit rates) while the NRT quit rates had fallen (<10%).

Mediational analyses shows that ACT works through acceptance and response

flexibility.

3) Gregg, et al. conducted an RCT (N = 81) showing that ACT + patient education is

significantly better than patient education alone in producing good self-management

and better blood glucose levels in lower SES patients with Type II diabetes [16]. Effects

at follow up are mediated by changes in self-management and greater psychological

flexibility with regard to diabetes related thoughts and feelings.

4) Vowles et al. conducted a well controlled RCT (N = 74) in with patients with

chronic low back pain are assigned to very brief acceptance, pain control, or practice

conditions and given physical tasks to perform[15]. The acceptance group improved the

most.

5) Wicksell et al. conducted a small RCT (N = 21) comparing ACT to TAU with

whiplash patients [55]. They found significant differences in pain disability, life

satisfaction, fear of movements, depression, and psychological flexibility (pain related

fusion and acceptance as measured by Wicksell’s Psychological Inflexibility in Pain Scale

or PIPS). Improvements in the treatment group were maintained at 7-months follow-up.

Mediation results reported in: Wicksell, R. K., Olsson, G. L., & Hayes, S. C. (in press).

Processes of change in ACT-based behaviour therapy: Psychological flexibility as a


mediator of improvement in patients with chronic pain following whiplash injuries.

European Journal of Pain. Found that follow up changes in life satisfaction and to a

lesser degree pain disability were mediated by post PIPS scores.

6) Wicksell et al conducted a Small RCT (n = 32) comparing a brief ACT intervention

(10 individual sessions) to multidisciplinary treatment plus amitriptyline (MDT) for

chronic paediatric pain [56]. Treatment continued in the MDT condition during the 3.5

and 6.5 month follow-up, which complicated comparisons at follow-up assessments due

to more sessions for MDT, but results showed substantial and sustained improvements

for the ACT group. When follow-up assessments were included, ACT performed

significantly better than MDT on perceived functional ability in relation to pain, pain

intensity and pain related discomfort (intent-to-treat analyses). At post-treatment,

before the dose differences happened, significant differences in favour of the ACT

condition were also seen in fear of re/injury or kinesiophobia, pain interference and in

quality of life.

7) Johnston, et al, conducted a very small RCT (N = 14) showing that ACT

bibliotherapy (Dahl & Lundgren, 2006 ) helps with chronic pain [57].

8) Wetherell conducted an RCT (N=114) comparing ACT and traditional CBT for

chronic pain [58]. Good outcomes over 6 months. No differences in outcomes.

Treatment completers were more satisfied with ACT.

9) Thorsell et al conducted an RCT (N = 90) of ACT versus applied relaxation using a

combination of an initial face to face session, a 7 week self-help manual with weekly


therapist telephone support, and a concluding face-to-face session [59]. 6 and 12 mo

follow up. Better outcomes for ACT in level of function, pain intensity, acceptance, and

marginal life satisfaction. Depression and anxiety improved but no diff between

conditions.

10) Rost, et al. conducted an RCT (N = 31; 47 originally but the rest died or

entered hospice care) comparing ACT and traditional CBT approaches to women coping

with end-stage gynaecological cancer[60]. Nice outcomes; dominantly in favour of ACT.

11) Jensen et al conducted the first RCT to do pre - post fMRI assessments in

the psychosocial treatment of chronic pain. (N = 43; all female; all w/ Fibromyalgia)

[61]. This is an ACT study with a wait-list control. 12 weekly group sessions and 3 mo f-

up. Better outcomes on depression, anxiety, and self-reported global change (activity

limitation, symptoms, emotions, quality of life).

12) Mo’tamedi, et al. conducted A small RCT (n=30) with a medical treatment

as usual control condition[62]. Chronic tension type of headache (63%) and chronic

migraine without aura (37%) were the headache types reported by the participants.

Data analyses indicated the significant reduction in disability (F[1,29] = 33.72, P <

.0001) and affective distress (F[1,29] = 28.27,P < .0001), but not in reported sensory

aspect of pain (F[1,29] = .81, P = .574), in the treatment group in comparison with the

control group. Consistent with other ACT pain studies.


48

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