Patient Experience and Satisfaction With Acceptance and Commitment Therapy Delivered in a Complimentary Open Group Format for Adults With Eating Disorders.

We examined patient experiences and satisfaction with acceptance and commitment therapy (ACT) delivered in a novel weekly open-group therapy format immediately following psychiatric intake assessment into a hospital-based outpatient adult eating disorders program. Participants were 68 adults with a Diagnostic and Statistical Manual of Mental Disorders, 5th edition diagnosis of an eating disorder who reported their experiences and satisfaction with the ACT group. Participants reported that they were somewhat satisfied to very satisfied with the open ACT group and that the treatment content was helpful. Specifically, participants reported that ACT group helped them to recognize their personal values and learn strategies for behavior change. Satisfaction with ACT group was associated with engagement in the broader group therapy program. Results suggest that ACT delivered in an open group format is well liked by adults in an outpatient program for eating disorders. ACT is a promising complimentary treatment for individuals with eating disorders that can be easily integrated by clinicians into outpatient care.

Engaging individuals with eating disorders in their recommended care is a well-known challenge in the field. Starting well in treatment is critical, with the process of waiting for the initiation of evidence-based care having a potential negative effect on patient motivation and symptoms (1,2). Eating disorder treatment is complicated by the unique nature of anorexia nervosa (AN) with aspects of the illness congruent with an individuals’ value system (3). The ego syntonic nature of AN may represent an important target in the early stages of treatment to engage patients in therapy (3,4). There is some evidence to suggest that patients’ early experiences in eating disorder treatment are important for their continued participation in recommended care (5). Although at times overlooked as part of routine clinical care, patient experience and satisfaction with treatment is an important variable in the field of adult eating disorders as it has been associated with individuals’ decisions to end recommended care prematurely (5 –7). Although there have been studies that have reported on patients’ experience and satisfaction in the treatment of eating disorders (8 –10), few studies have examined the potential association between patients’ satisfaction with treatment and their engagement in evidence-based care.

Acceptance and commitment therapy (ACT) has been argued to be well suited as an adjunct treatment for eating disorders, particularly during the initial stages of care (11). ACT is a third-wave cognitive behavioral therapy (CBT), which extends and modifies traditional CBT approaches by emphasizing the importance of accepting symptoms as they are, while also committing to work toward personal values and goals (12). A main objective of ACT is to increase psychological flexibility, which is thought to benefit patients with eating disorders who are often inflexible in their thinking (11). Another important ACT treatment target for individuals with eating disorders is to help them identify and live in line with their personal values (12). Aspects of eating disorders may be congruent with an individuals’ value system (3). Consequently, the ego syntonic nature of eating disorders may represent an important target in the early stages of treatment to engage patients in therapy (3,4,13). In ACT, patients work toward a shift from values twisted by the eating disorder (eg, activity and health directed toward weight loss) back to personal values (eg, activity and health for general wellness) (13). ACT is also useful in decreasing avoidance behavior. Recent theoretical models of the illness have proposed that individuals with eating disorders may engage in nutritional restriction to avoid distress (14 –16). Through ACT, patients learn to tolerate and accept distress, which may in turn reduce nutritional restriction.

Preliminary work has shown that patients with eating disorders readily engage in ACT and experience improvements in their weight status, self-reported psychological symptoms, and overall quality of life after participating in ACT (17 –19). This initial work has predominantly consisted of case reports that describe patients’ engagement in ACT and their outcomes. Berman and colleagues found that the 3 participants in their case series experienced positive changes in their weight status and eating disorder symptoms after engaging in ACT (17). Similarly, a case report of 2 individuals who voluntarily participated in ACT found that patients experienced a decrease in the average number of self-reported emotional eating episodes posttreatment and that these gains were maintained at a 3-month follow-up (19). In addition to individual therapy, ACT has recently been adapted for delivery in group therapy formats for addressing eating disorder symptoms in residential and inpatient treatment settings. Preliminary data indicate that patients were satisfied with ACT and that the treatment was effective in reducing eating disorder pathology (11,20).

In the current study, we report on ACT delivered as a complimentary treatment (ie, to the broader group therapy program) offered to adults with a Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (21) diagnosis of an eating disorder immediately after completing their psychiatric intake assessment. Delivery of ACT in an open group format is aimed to address the lag between receiving an initial psychiatric assessment and the initiation of evidence-based care. The ACT group was positioned as a complimentary treatment that patients could engage in immediately after completing their psychiatric intake assessment. We examined patient experience (ie, descriptive statements of what patients liked and disliked) and satisfaction with ACT. We also examined whether participants’ self-reported satisfaction with the open ACT group was associated with their engagement in the broader group therapy programming. The current study provides novel insights into implementing an open ACT group format that may be practical for clinicians in hospital-based outpatient care settings.

Methods

Participants and Procedure

Participants were 68 adults (61 females, 7 males) who met DSM-5 criteria for an eating disorder and were accepted for treatment at a tertiary-level, hospital-based outpatient adult eating disorders group therapy program. Participants mean age was 27.54 years (standard deviation [SD] = 11.03). Overall, 25.0% of the sample met criteria for AN, 27.9% for bulimia nervosa (BN), 26.5% other specified feeding or eating disorder (OSFED)–atypical AN, 11.8% OSFED–BN, 5.9% OSFED–binge eating disorder, and 2.9% unspecified feeding or eating disorder. The clinic offered the open ACT group from 2013 to 2016. Participation in the ACT group was voluntary. Inclusion criteria were that participants were 18 years of age or older and were accepted to the broader outpatient group-based therapy program for adult eating disorders. Individuals who did not consent to participate in the study were still able to participate in the ACT group post-intake assessment as part of their care.

The majority of participants (80.9%) met criteria for a comorbid mood or anxiety disorder. The group therapists included a licensed clinical psychologist with formal training in ACT and over 8 years of experience working in the field of eating disorders, as well as clinical psychology practicum students and psychiatry residents who helped to cofacilitate the group. Weekly ongoing supervision and consultation were provided for treatment adherence, which included some training by the psychologist provided to cofacilitators in the core components of ACT, review of the group session-by-session handouts, and debriefing after each group session to address any therapeutic drift from the model. This study met ethical approval through the University Health Science and Affiliated Teaching Hospitals Research Ethics Board as part of the clinics ongoing program evaluation research.

Acceptance and Commitment Therapy Group Overview

ACT was delivered in a novel weekly open group format where participants were able to engage in the group immediately after completion of their psychiatric intake assessment. There was no limit on the number of participants who could engage weekly in the open ACT group. The average number of participants who engaged in the ACT group on a weekly basis was 4.12 (range, 1-12). The ACT group was based on current and emerging best practices in the treatment of adult eating disorders using ACT and was delivered in weekly 60-minute sessions (20,22). Modification of select ACT defusion skills from Get out of Your Mind and Into Your Life, The Happiness Trap: Stop struggling, start living, and CBT-practitioner’s guide to ACT: How to bridge the gap between cognitive behavioral therapy and acceptance and commitment therapy were also included as part of the group content (12,23,24). Some of the specific topics covered included a values card sort task with a discussion of personal values (25), how the eating disorder may be acting as a barrier to valued living, and values that have been twisted by the eating disorder (eg, health and fitness as a value that is taken to an unhealthy extreme by the illness). The ACT group content also included a weekly values check in, 90th birthday card activity, barriers to valued living, control of thoughts and feelings, quicksand metaphor, hooking thoughts, chessboard metaphor, evaluations versus descriptions, evaluations as prison bars, ABCDE worksheet, and mindfulness activities. Some examples of task modification included the tug of war with the anxiety monster metaphor, which was modified to discuss how the eating disorder may pull on the middle of the rope providing some slack or short-term relief from anxiety, while at the same time inching the person closer to the pit. Passengers on the bus metaphor was modified to acknowledge that the eating disorder may have the person negotiate and make deals with their passengers to experientially avoid distress (eg, if I overexercise after a meal you will quiet down back there).

A total of 16 sessions of ACT were provided on an ongoing weekly basis. Patients who engaged in ACT group received ongoing medical monitoring while participating in the group as part of their routine care. Each ACT group session began with a homework review, followed by a values check-in where participants were asked to identify a value separate from the eating disorder that was important to them, an overall goal and a specific action they could engage in to be more in line with that value, and to identify any barriers that may get in the way. The main session content was spent on a topic related to 1 of the 6 core components of ACT (ie, acceptance, values, committed action, using self as a context, contact with present moment, and defusion). Sessions 1 through 4 focused on socialization to the ACT model, clarification of values outside of the illness, and working toward committed action in line with those values. Session 5 through 8 focused on acceptance and sessions 8 through 10 emphasized mindfulness and present-moment awareness. Sessions 10 through 13 included work on using self-as-context, and sessions 13 through 16 are focused on defusion. The broader group therapy program included a 16-session CBT group based on current best practices in the treatment of eating disorders and with pilot data published on the group (1,26,27), a 12-session exposure with response prevention group for body satisfaction (28), nutrition counseling groups, and additional adjunct therapy groups (eg, cognitive remediation therapy) (29).

Measures

Demographic characteristics and diagnosis

Patients provided demographic information (eg, age, sex) as part of the initial psychiatric assessment. DSM-5 diagnoses were provided through clinical interview at intake assessment into the clinic by psychiatrists who had a specialization in adult eating disorders with accompanying psychometric measures administered by a clinical psychologist.

Patient experience and satisfaction with ACT group

Participants completed a brief self-report questionnaire at the end of each open ACT group session. This questionnaire was a clinic-specific measure developed in part based on the Treatment Satisfaction Scale (8), which is one of the few available measures of patient satisfaction for adults with eating disorders. Modified versions have been used in other work with adult outpatients with eating disorders (26). Participants were asked to rate how satisfied they were with the ACT group on a 5-point Likert-type scale (1 = not satisfied, 2 = a little satisfied, 3 = neutral, 4 = somewhat satisfied, 5 = very satisfied). Responses on this item were averaged across each participant. Participants responded to one item on whether they found the open ACT group “helpful” using a force choice response format (yes/no). All participants had the option of providing a descriptive statement of what they “liked” or “disliked” about the open ACT group.

Results

Participants attended an average of 3.63 sessions of ACT group (SD = 3.90, range 1-16). Attendance was not associated with age (r = −.18, p = .15), sex (t 66 = 0.06, p = .95), or DSM-5 diagnosis (F 5, 62 = 0.74, p = .60). Average participant satisfaction with the ACT group was 4.44 (SD = 0.77, range 2-5) or somewhat satisfied to very satisfied. All participants rated the group as “helpful” at the end of each session. Participant satisfaction with the ACT group was not associated with the number of sessions they attended (r = .13, p = .31), age (r = .10, p = .41), sex (t 66 = 0.07, p = .95), or diagnosis (F 5, 62 = 0.42, p = .83).

Participants’ descriptive statements about their experience and satisfaction with the open ACT group are listed in Table 1. In general, participants reported enjoying that ACT helped them to recognize their personal values and prioritize recovery, the applicability of the activities to eating disorders, and the strategies that facilitated behavior change. When asked what they disliked, they reported wanting more of the ACT sessions to be at different times during the week and more time in group to relate activities to daily life outside of the illness.

Table 1.

Participants’ Statements About What They Liked or Disliked About the ACT Group.

Liked	Disliked
I like the way the activities started unrelated to eating disorders but were brought around to eating disorders at the end	More time at the end to relate to normal life
It’s helping me to work through strategies and make efforts to move toward changing	More sessions [at] different times
Enjoy flexibility in what we talk about. [The ACT therapist] is very open
Helped me to recognize my values and prioritize recovery

Abbreviation: ACT, acceptance and commitment therapy.

The majority of participants (73.5%) in the open ACT group continued attending the broader group therapy programming after engaging in the open ACT group. A logistic binary regression analysis with satisfaction with ACT group and the number of ACT sessions attended entered as predictor variables, and later participation in the broader group programming entered as the outcome variable was used to examine whether satisfaction with ACT group was associated with participation in the broader clinic group programming. The logistic regression model was statistically significant, χ2(2) = 17.43, p < .001. The model explained 33% (Nagelkerke R 2) of the variance in attending later core group programming. The number of sessions participants attended was not a unique predictor of engagement in later core group programming, B = .25, standard error (SE) = .15, Wald’s χ2(1) = 2.75, p = .10, eB = 1.29 (95% confidence interval [CI]: 0.96-1.74). Satisfaction with ACT group was a unique predictor of participation in later core group programming, B = 1.23, SE = .46, Wald’s χ2(1) = 7.24, p = .006, eB = 3.41 (95% CI: 1.40-8.32). With every 1 unit increase in satisfaction with the open ACT group, participants were 3.41 times more likely to attend later core group programming.

Discussion

The current study extends prior work by providing initial results on patient experience and satisfaction with ACT delivered in an open group therapy format as a complimentary outpatient treatment for individuals with an eating disorder. Participants viewed this group as helpful. Descriptive statements by participants noted that their engagement in the ACT group helped with clarifying personal values outside of the eating disorder, prioritizing recovery, and encouraging positive efforts toward behavior change. Although patients with eating disorders can be challenging to engage in treatment (3,4), our results suggest that ACT offered as an open group is well received by patients. Overall, participants reported feeling satisfied with ACT delivered in this outpatient open group format.

Patients’ self-reported satisfaction with the ACT group was associated with engagement in the broader clinic group programming. There are several factors that are unique to ACT that may account for this association. For example, ACT delivered early in treatment (ie, when the eating disorder is at its “loudest”) may help to actively engage patients in their treatment and recovery. It may also provide a platform for patients to discuss internal struggles with decisions to move toward recovery or back into the arms of the illness. In addition, ACT helps patients to differentiate illness-based values versus personal values, which may be an important first phase in engaging patients in recommended care (13, 16). Finally, satisfaction with ACT may be a proxy of satisfaction with treatment in general. Although a strength of this work is the ecological validity of the study conducted in a fully functioning hospital-based outpatient clinic, future work with experimental design is necessary to investigate whether satisfaction with ACT group leads to future engagement in programming, and to identify potential mechanisms underlying this relation.

ACT has been successfully delivered in open group therapy formats for addressing eating disorders in residential settings (11). However, the ACT group described in the current study was unique in several ways. First, this study was the first to use an open group therapy format for ACT in a specialized outpatient setting for adult eating disorders offered immediately after psychiatric intake assessment into a broader group-based program. Second, this study explored ACT offered as a transdiagnostic open group treatment, rather than tailoring the treatment to patients of specific diagnostic categories (eg, AN and BN). Third, ACT was delivered in a 16-session model congruent with other programming offered in a similar duration in the outpatient clinic, whereas other work has consisted of 8 sessions offered twice weekly (11,20). Our results provide preliminary support for the usefulness of ACT delivered in this format for outpatient care.

In the present study, participants reported that they enjoyed the flexibility in what was discussed in ACT group and that the ACT therapist was perceived to be very open with group members. This finding is consistent with past work showing that individuals with eating disorders are more satisfied with their therapists when they perceive them to be more accepting and challenging (30). In her recent review of novel approaches for addressing eating disorders, Thompson-Brenner discussed the important role of the therapeutic alliance in helping to increase patient motivation for behavior change (31). In fact, when individuals struggling with eating disorders view treating professionals as being competent, patients report higher levels of satisfaction with the treatment they receive compared to patients who do not believe their therapist is competent (30). Taken together, the emphasis on the therapeutic alliance in ACT may be particularly important for patients with eating disorders and may be an important area for future study.

Although the average number of ACT group sessions attended was relatively low (ie, 3.63), other work argued that attendance in at least 3 ACT group sessions represents a minimum acceptable dosage for participants (11). Participant numbers in ACT group was likely affected by other treatment groups available in the clinic to participate in (eg, CBT, cognitive remediation therapy, etc), and there were no expectations that participants should attend all sessions. Participants in ACT delivered in open group therapy formats may respond better to other group members’ discussions of engagement in experiential avoidance that provides opportunities for interpersonal learning within the group milieu (20). Given that the ACT stance does not have symptom reduction as its main goal and that the open format allowed for participants themselves to decide whether or not they engaged in care, these factors may have made it more palatable to patients early in their engagement in treatment for an eating disorder. More research is needed to examine the relationship between participants who opt to engage in open ACT group versus those who do not (ie, within the same outpatient adult eating disorders program) and their decisions to engage in the broader group programming.

Limitations

Although this study adds to the growing literature on ACT for addressing symptoms of an eating disorder by examining patients experience and satisfaction with this treatment in an ecologically valid setting, there are limitations. The current study is cross-sectional, and as a result, it is not clear whether satisfaction with ACT is causally associated with engagement in further treatment programming. Further, other types of treatment (eg, psychoeducation, process oriented treatment) offered immediately after psychiatric intake assessment may also be related to engagement in the broader programming. Future work is needed to disentangle whether it is the treatment itself or having some therapeutic contact early in the process of care that is helpful for individuals.

Treatment fidelity was not directly assessed in the current study. We did, however, adhere to weekly handouts and materials outlining ACT group content and sessions, and all therapists participated in weekly supervision provided by a psychologist trained in ACT and with experience in treating eating disorders (which helped modify the ACT contents in a meaningful way). Future work could improve treatment fidelity in additional domains by formally measuring how participants receive and enact what they have learned and implementing fidelity checks of audio-recorded group sessions for adherence. This may help to certify that participants received the key elements of ACT as intended and that they were actively using the concepts outside of the group. In addition, we did not have adequate power in this study to examine potential moderators (eg, age) of the relationship between self-reported satisfaction with the ACT group and treatment engagement. Finally, the findings from this work are generalizable not only to individuals with eating disorders but more specifically to individuals who have been accepted for treatment at a specialized tertiary-level hospital-based adult outpatient treatment program.

Conclusion

In summary, ACT provided in an open group therapy format may provide a viable option for engaging patients in care immediately after completion of psychiatric assessment into a hospital-based outpatient eating disorders program. ACT was well liked and viewed as being helpful by the patients themselves and can be easily integrated to help compliment preexisting treatment programming.