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The Role of Values in Eating Disorders Treatment

Eating disorders are phobic disorders; therefore, we have to challenge the phobia and support patients in confronting their fears. To do so, we must find something they value more than their eating disorder, something that's so important to them that it overrides this anxiety.
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The women, men and children struggling with eating disorders have world-class anxiety, and they use their eating-disordered thoughts and behaviors to manage their anxiety. As a result, addressing anxiety is key to effective intervention and sustainable recovery.

The treatment community has found that an effective way to address anxiety in eating disordered patients is through the use of values.[1] When we talk about values, we're not only identifying what patients value, but evaluating whether their eating disorder is helping them work toward the things that are important to them, or if it's actually keeping them from living their values and achieving their goals. Unfortunately, it's usually the latter outcome, which presents an opportunity for eating disorders treatment professionals to help demonstrate a path for recovery that aligns with the things in life that these patients hold dear.

A thought leader on the role of values in eating disorders treatment is Emmett R. Bishop, Jr., MD, FAED, CEDS, medical director of adult services at Eating Recovery Center. Below, he answers common questions around the use of values-based anxiety management in eating disorders recovery.

How do values assist in anxiety management?

Oftentimes, individuals use destructive thoughts or behaviors to self-soothe and "escape" painful thoughts, feelings or experiences. Values-based anxiety management is when we work with anxious patients to identify what they value in life and help them see how their values can trump their anxiety. It's all about understanding that there are things that they value more in life -- family or intimate relationships, education, professional success, honesty, spirituality and the like -- than escaping their anxiety.

How does values-based anxiety management help people with eating disorders?

Eating-disordered individuals manage their anxiety with an eating disorder, be it anorexia, bulimia, binge eating disorder or eating disorder not otherwise specified (EDNOS). They'd much rather find an escape mechanism -- such as eating disordered behaviors -- than deal with their anxiety. However, managing anxiety with an eating disorder keeps anxiety between patients and what they value.

To understand the role of values in eating disorders treatment, it's important to acknowledge a few key characteristics about the minds of patients struggling with these illnesses. In general, they display traits of anxiety, rigidity and inability to see "the big picture." And it's these traits that maintain eating disorders and keep patients from identifying and living their values. Because traits don't change, we have to help patients manage the traits that they cannot readily eliminate and "play the hand they've been dealt." From a biological perspective, eating-disordered patients have starving brains with significantly less activity in the prefrontal cortex, the part of the brain that allows them to see the "big picture."[2] Additionally, intense anxiety from the amygdala -- the emotional brain -- further inhibits the prefrontal cortex, making it difficult for eating-disordered individuals to maintain a self-observing stance and think critically about how they're living out their values, particularly when thinking about sensitive topics like food and body size.

Eating disorders are phobic disorders; therefore, we have to challenge the phobia and support patients in confronting their fears. To do so, we must find something they value more than their eating disorder, something that's so important to them that it overrides this anxiety. Because eating disorders patients generally have low self-directedness, values identification gives patients something to direct their lives towards.

Here's a good example. I worked with a woman who was continually delaying her wedding because she couldn't imagine getting married while still struggling with her eating disorder. I helped her question her actions and determine whether they were helping her live her values or not. I asked her, "You've had this bulimia for over 20 years, but do you value this relationship with your fiancé? If you value this relationship, then you can't let the eating disorder stand in the way of moving this relationship forward." Once she was able to connect with her deeply-held value of protecting and nurturing her bond with her fiancé, she was able to give up the bulimic behaviors in order to fully pursue the relationship.

How are values used in the eating disorders treatment environment?

Acceptance and Commitment Therapy (ACT) is an intervention that hinges on values identification and the use of values to address the anxiety management component of the illness.[1] This behavioral therapy moves away from the notion of "changing cognitions" and eliminating those that elicit anxiety, and toward how people can live a valued life in the presence of negative thoughts and feelings. The goal of ACT is to help patients create a rich and meaningful life while accepting the pain that inevitably goes with it.

To help patients identify their values, we often use "The Valued Living Questionnaire" by Kelly Wilson, Ph.D. This tool allows patients to really articulate what they value in life, and look critically at how well they've lived those values in the past and present. Joanne Steinwachs, LCSW, created a series of values flashcards that have also been helpful in getting patients to reflect on and identify the thoughts, feelings and achievements they value through brainstorming.

Another way to think about the use of values in the treatment environment is that we're trying to change the patient's "job description" from an "anxiety manager" to a "values director." Patients strive to focus on their values versus escaping and avoiding anxiety through disordered eating behaviors.

Visit Eating Recovery Center's website for more information about values and Acceptance and Commitment Therapy in eating disorders treatment.


[1] "The Use of Acceptance and Commitment Therapy (ACT) in the Treatment of Eating Disorders," delivered on August 20, 2011 by Enola Gorham, LCSW, CEDS, Clinical Director of Adult Services at Eating Recovery Center, at the Rocky Mountain Eating Disorders Conference.
View session here.

[2] "Cognitive Remediation Therapy for Eating Disorders: A New Adjunct to Treatment,"
delivered on August 3, 2012 by Emmett R. Bishop, MD, FAED, CEDS, Medical Director of Adult Services at Eating Recovery Center, at the Eating Recovery Center Foundation Eating Disorders Conference.
View session here.

For more by Kenneth L. Weiner, M.D., FAED, CEDS, click here.

For more on eating disorders, click here.

If you're struggling with an eating disorder, call the National Eating Disorders helpline at 1-800-931-2237.