Author's Accepted Manuscript
Baseline Eating Disorder Severity Predicts
Response to an Acceptance and Commitment
Therapy-based Group Treatment
Adrienne Juarascio, Stephanie Kerrigan, Ste-
phanie P. Goldstein, Jena ShawM.S. , Evan M.
Forman, Meghan Butryn, James D. Herbert
To appear in:
Journal of Contextual Behavioral Science
Received date: 9 April 2013
Accepted date: 16 September 2013
21 August 2013
Cite this article as: Adrienne Juarascio, Stephanie Kerrigan, Stephanie P.
Goldstein, Jena ShawM.S. , Evan M. Forman, Meghan Butryn, James D. Herbert,
Baseline Eating Disorder Severity Predicts Response to an Acceptance and
Commitment Therapy-based Group Treatment, Journal of Contextual Behavioral
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Running Head: ACCEPTANCE AND COMMITMENT THERAPY FOR EATING DISORDERS
Baseline Eating Disorder Severity Predicts Response to an Acceptance and Commitment Therapy‐based
Adrienne Juarascio, Ph.D., Stephanie Kerrigan, B.A., Stephanie P. Goldstein, B.S., Jena Shaw, M.S., Evan
M. Forman, Ph.D., Meghan Butryn, Ph.D., James D. Herbert, Ph.D.
Department of Psychology, Drexel University, Philadelphia, PA, USA
Correspondence concerning this article should be addressed to Adrienne Juarascio, Department of
Psychology, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104.
Running Head: ACCEPTANCE AND COMMITMENT THERAPY FOR EATING DISORDERS
Baseline Eating Disorder Severity Predicts Response to an Acceptance and Commitment Therapy‐based
The present study investigated whether more severe baseline eating pathology (e.g. baseline
symptomatology, previous hospitalizations, and low weight in anorexia nervosa) moderated the effect
of an Acceptance and Commitment Therapy (ACT)‐based group treatment. Participants were 140
women who were admitted to an inpatient facility for eating disorders. Women were categorized as
anorexia nervosa spectrum or bulimia nervosa spectrum at intake and completed measures of eating
pathology. All participants received comprehensive treatment, and those in the treatment‐as‐usual plus
ACT condition received twice weekly ACT group treatment. At post‐treatment (i.e., at discharge from
the facility), participants completed measures again. Severity of self‐reported eating symptomatology
moderated treatment such that those with more severe symptoms at baseline showed greater
improvements in eating disorder symptomatology in the ACT condition than in the treatment‐as‐usual
condition. Additionally, trends showed similar patterns for those with more previous hospitalizations
and those on the anorexia nervosa spectrum who had lower body weights. The magnitude of
differences was modest, but indicate that an acceptance‐based treatment may be a beneficial for
patients with more severe eating disorder pathology.
Eating disorders, particularly among adult patients with a long course of illness, are
exceptionally difficult to treat. Patients presenting for admission to inpatient treatment centers
frequently have a long course of illness, are more symptomatic (compared to patients presenting for
outpatient treatment), and have previously been hospitalized (Vrabel, Rosenvinge, Hoffart, Martinsen,&
Rø, 2008), all of which predict poor treatment outcome (Vandereycken, 2003). More than half of
patients still meet criteria for an eating disorder up to five years following discharge from a residential
treatment facility (Rø, Martinsen, Hoffart, & Rosenvinge, 2004; Vrabel et al., 2008) and nearly half have
another hospitalization during that same follow‐up period (Vrabel et al., 2008).
Cognitive Behavioral Therapy (CBT), particularly versions specific to eating disorder
symptomatology, is the current treatment of choice for eating disorders. Among patients with bulimia
nervosa (BN), CBT‐BN (a targeted CBT treatment for BN) and CBT‐E (an “enhanced” CBT for eating
disorders which builds on CBT‐BN by including optional modules for hypothesized maintenance factors
such as perfectionism, low self‐esteem, and interpersonal deficits) both produce large reductions in
binge eating, purging, and other compensatory behaviors (Fairburn et al., 2009, Fairburn, 2008;
Treasure, et al., 1994) that tend to be well maintained over time (Waller et al., 1996). Despite this, a
large subset (30‐50%) of patients remains symptomatic following treatment (Fairburn, 2008; Wilson,
2005). In the case of anorexia nervosa (AN), Family Based Therapy (FBT) is effective for adolescences
with a relatively short duration of illness, but an effective treatment remains to be seen for adults (Lock,
2011) (Fisher, Hetrick, & Rushford, 2010). Brief manualized CBT appears to have little efficacy for AN
(McIntosh et al., 2005; Wilson, Grilo, & Vitousek, 2007); CBT‐E appears to be only moderately more
successful (Fairburn et al., 2009). In two recent studies of CBT‐E, only 60% of underweight patients
agreed to engage in treatment and, of those, 50‐60% showed a response to treatment (Bryne, Fursland,
Allen, & Watson, 2011; Fairburn et al., 2009).
Identifying patients who are likely to benefit from specific treatments can allow clinicians to
choose the treatment approach most likely to be effective. Only recently has the field begun to examine
how patients with more severe eating pathology may respond differentially to treatment. Grilo and
colleagues (2012) reported that among patients with binge eating disorder (BED), those with low self‐
esteem, negative affect, and overvaluation of shape and weight at baseline improved more in CBT
compared to medication (Grilo, Masheb, & Crosby, 2012). However when examining CBT alone,
Castellini (2012) found that patients with BED who had a lower frequency of binging, lower impulsivity,
and greater emotional stability improved more with CBT than patients with more severe pathology.
Butryn and colleagues (2006) found that patients with BN who have greater weight suppression
(difference between premorbid and pretreatment weight) showed poorer post‐treatment outcomes.
Other studies have found that baseline symptomatology, course of illness, prior hospitalizations, and
weight at baseline put patients at high risk for treatment failure from existing treatment approaches
(Vandereycken, 2003; Vrabel et al. 2008). Much of the evidence suggests that CBT is most effective for
patients with less severe eating pathology. Overall, although CBT has been shown to result in statistically
significant reductions in eating pathology for some, there remains much room for improvement,
particularly for patients with more severe pathology.
A growing body of research indicates that Acceptance and Commitment Therapy (ACT) may be
an effective treatment option for patients with eating disorders. Several pilot studies of acceptance‐
based therapies such as dialectical behavioral therapy (Safer, Telch, & Chen, 2009), mindfulness‐based
cognitive therapy (Kristeller, Baer, & Quillian‐Wolever, 2006), and functional contextual treatment
(Anderson & Simmons, 2008) have demonstrated initial success in treating BED and BN. Similarly, a
series of case reports have indicated that patients with treatment‐resistant AN may benefit from ACT
(Berman, Boutelle, & Crow, 2009). Though few, the studies conducted on ACT for eating disorders have
been promising (Berman et al., 2009; Heffner et al., 2002; Juarascio, Forman, & Herbert, 2010; Juarascio
et al., 2013; Timko, Zucker, & Merwin, 2012).
ACT may particularly benefit those patients with more severe eating pathology. Given the ego‐
syntonic nature of eating disorder pathology, many patients, particularly those who are more severe,
are reluctant to engage in treatment (Fairburn, 2008; Schmidt & Treasure, 2006). Eating disorders are
characterized by high experiential avoidance (Cockell, Geller, & Linden, 2002; Keyser et al., 2009; Mizes
& Arbitell, 1991; Orsillo & Batten, 2002), and the degree of experiential avoidance is cross‐sectionally
related to eating disorder symptom severity (Butryn et al., 2012). Cognitive rigidity, frequently seen in
more severe cases of AN, has also been shown to be related to severity of disordered eating behaviors
(Masuda, Price, Anderson, & Wendell, 2010). The focus on increasing psychological flexibility during an
ACT‐based treatment may help to decrease this rigidity, thereby allowing patients a greater ability to
engage in values‐based behavior change. Overall, there is a strong theoretical link between ACT‐based
treatment and eating disorders, particularly in more severe and treatment refractory cases. However,
no studies have examined the moderating effect of eating disorder symptom severity on acceptance‐
based treatment outcomes.
The current study utilized data from a recently published report that investigated treatment‐as‐
usual (TAU) compared to TAU+ACT for eating disorders at an adult residential facility (Juarascio et al.,
2013). Patients at this facility tended to be in the more severe range of eating pathology, although the
degree of severity varied widely in terms of length of illness, severity of disordered eating behaviors, and
weight at admission. Prior research has found that most patients undergoing TAU at this facility
experienced large improvements in disordered eating by post‐treatment but remained partially
symptomatic and often relapsed by six month‐follow‐up, leaving significant room for improvement
(Juarascio et al., 2013; Lowe, Davis, Annunziato, & Lucks, 2003). Thus, researchers added twice weekly
ACT groups for eating disorders to TAU and compared improvements in those receiving ACT+TAU to TAU
alone. Standard ACT exercises were modified to make the protocol more specific to eating disorders
(see contextualscience.org for manual). The initial report demonstrated that although both conditions
showed large improvements from pre‐ to post‐treatment, ACT+TAU trended towards faster and larger
improvements in eating pathology (p=.07), shape concern (p=.07), and weight concern (p=.09; Juarascio
et al., 2013). Using this database, we assessed how patients with more vs. less severe eating disorder
symptomatology responded to ACT + TAU vs. TAU alone.
Moderators for the current study were chosen based on previous literature. Because patients
with higher symptomatology may be at higher risk for treatment failure from standard behavioral
treatments (Vrabel et al., 2008), we hypothesized that baseline symptom severity would moderate the
effect of treatment condition, such that the advantage of ACT+TAU would be more pronounced among
those endorsing more severe symptomatology. Furthermore, previous hospitalizations and weight at
baseline have both been identified as risks for treatment‐resistance and poor outcome (Vandereycken
2003). We hypothesized that patients entering treatment with a prior hospitalization and lower weight
at baseline (among AN patients) would show greater improvements in ACT+TAU compared to TAU.
The study took place at a residential treatment facility for women with eating disorders in the
Mid‐Atlantic region of the United States (The Renfrew Center in Philadelphia, Pennsylvania). All
participants had a diagnosis of AN, BN, or eating disorder not otherwise specified in the AN or BN
spectrum, based on the criteria from the Structured Clinical Interview for DSM Disorders (SCID; First,
Spitzer, Gibbon, & Williams, 2002). There were no other exclusion criteria, and patients with co‐morbid
disorders were included in the study. A total of 140 women consented to take part in the study. The
average age of the sample was 26.74 years (SD= 9.19), with a range of 18‐55. The sample was
predominantly Caucasian (89.3%), with small proportions of other racial groups (African American=3.6%,
Asian=2.1%, Hispanic=2.9%, Other=1.4%). The sample had a relatively long eating disorder history (M=
10.75 years since onset, SD= 9.08) with an average age of onset at 16.43 years (SD=5.5). We grouped
individuals with EDNOS into AN‐spectrum (i.e., < 85% of their ideal weight; n=66, 47.1%) or BN‐spectrum
(i.e., ≥ 85% of ideal weight and exhibited binge eating and/or compensatory behaviors; n=74, 52.9%)
diagnoses, based on recommendations from prior studies (Fairburn & Walsh, 2002; Walsh & Garner,
Twenty women did not return pre‐treatment questionnaires after providing informed consent
because they were no longer interested in participating (n=18) or because they left the unit due to
difficulty obtaining insurance coverage (n=2). Retention was high throughout the study, with 111
(92.5%) completing post‐treatment questionnaire packets for eating disorder outcome variables
(ACT+TAU=58, TAU=53). ACT+TAU participants attended 4.75 (SD= 2.51, range 0‐11) group sessions on
average. Treatment completers, defined as those attending 3 or more group treatment sessions (n=56,
of whom 52 completed post‐treatment measures; 93%), were equivalent to non‐group completers on
demographic and baseline variables, with only length of stay differing between the two treatment
conditions (Group completers: 28.83 days, SD=10.24, Non‐Group completers: 19.00, SD=8.36,
t(64)=2.86, p<.01). The results described below used the completer samples (ACT+TAU: 52 patients who
completed at least three groups and main outcome post‐treatment measures, TAU: all 53 patients who
completed main outcome post‐treatment measures), although similar results were observed for intent‐
Eating Disorder Examination Questionnaire (EDE‐Q; Fairburn & Beglin, 1994). The EDE‐Q is a
self‐report version of the Eating Disorder Examination interview. It covers a 4‐week time period
(although at discharge, patients were instructed to report on the time frame since beginning treatment
if this occurred less than 4 weeks prior to the post‐treatment assessment), and it assesses the core
features of eating disorders. Internal consistency and test‐retest reliability are both excellent (Luce &
Crowther, 1999). Cronbach’s alphas for the global subscale was .91.
Prior Hospitalizations. Prior hospitalizations were assessed via self‐report on an intake
questionnaire directly provided by The Renfrew Center.
Body Mass Index. Weight and height were assessed using a medical grade scale and a
Due to use of a pre‐existing residential treatment as a comparison condition, pure random
assignment was not feasible. We therefore used a nonequivalent groups design where half of the
participants received standard TAU and half received TAU+ twice‐weekly ACT groups. Given the threats
to internal validity observed in non‐equivalent group designs, a switching replication design was utilized
to ensure, as best as possible, that observed differences in groups were due to the interventions (Cook
& Campbell, 1979; Reichardt, 2005). Groups were run in three sequential phases and all participants
entering the treatment center during a given phase were assigned to the same condition. The order of
the sequence, i.e., TAU, ACT, TAU, was chosen through random assignment.
Assessments. Main assessments occurred at pre‐ and post‐treatment. For a full list of
assessment items administered and the assessment protocol, see Juarascio et al., (2013).
Treatment. Participants in the TAU condition received standard treatment at The Renfew
Center. Treatment at the residential facility is based on a comprehensive system designed to normalize
eating patterns, stabilize or increase weight, and eliminate compensatory behaviors. The theoretical
orientation of the program is eclectic and includes psychodynamic, feminist, interpersonal, and cognitive
behavioral components. Although most of the group and individual treatments are eclectic, many of the
more behavioral interventions inherent in the residential treatment program (i.e. regular weighing,
normalization of eating, feared food exposures) are components of CBT‐E (Fairburn, 2008).
Participants in the TAU+ACT condition received all TAU elements described above and also
received twice‐weekly ACT group treatment in lieu of regularly programmed staff‐run leisure groups.
The manualized group treatment was heavily based on exercises and discussions in existing ACT books
including “Get out of your mind and into your life” (Hayes & Smith, 2005) and “Acceptance and
Commitment Therapy” (Hayes et al., 2012), which were modified to focus on eating disorders. ACT
treatment was conducted by master’s‐level therapists with prior experience in treatment for eating
disorders and ACT. Additional information about the treatment manual, adherence, and competency
can be found in Juarascio et al. (2013) and Juarascio et al (under review).
To control for type 1 error, EDE global score, rather than individual subscale scores, was chosen
as the primary dependent variable. Three independent variables (baseline global EDE scores, prior
hospitalizations, and pre‐treatment weight) were chosen to assess baseline eating disorder severity. We
chose these three variables to obtain a more comprehensive profile of baseline eating disorder severity.
Correlations between the three independent variables ranged from nearly no relationship (e.g., prior
hospitalization to baseline EDE Global Score, r=.02, p=.85) to a small relationship (e.g. baseline weight in
AN patients and prior hospitalizations, r=‐.15, p=.27), but no correlation was significant (all p’s >.05),
further supporting the use of multiple methods of assessing baseline severity. Given the post‐hoc nature
of the current study, the sample size yielded low power to test the current hypotheses as this was not
the primary goal of the original study. Where possible, we thus emphasize patterns and size of effects
rather than formal statistical significance.
Hypothesis 1: Severity would moderate the effect of treatment condition, such that the
advantage of ACT+TAU will be more pronounced among those with greater eating pathology.
A regression analysis was conducted using EDE global score at baseline, condition, and the
interaction between condition and baseline EDE global scores (centered at a mean of 4.39) as the IVs
and EDE global score at post‐treatment as the DV. All terms were entered simultaneously. Results
revealed a significant effect of baseline EDE global scores (B=.67, S.E.=.13, p<.01), and trends for
treatment condition (B=‐.40, S.E.=.22, p=.07) and the interaction between treatment condition and
baseline EDE global scores (B=‐.30, S.E.=.18, p=.09). Overall, the patterns suggested that individuals with
higher baseline global eating pathology showed stronger benefits in the ACT+TAU condition (See Figure
1), but effect size was relatively small.
Hypothesis 2: Prior hospitalizations would moderate the effect of treatment condition, such that
the advantage of ACT+TAU will be more pronounced among those with prior hospitalizations
Patients were grouped into no previous hospitalizations (n=60) and at least one previous
hospitalization (n=43). A repeated‐measures ANOVA was conducted to assess the interaction between
assessment point, condition, and prior hospitalizations. No significant results emerged for EDE Global
Scores (F(1, 98)=2.76, p=.09, ηp
2=.02). However, the pattern of results closely mimicked those observed
in hypothesis 1, such that patients with prior hospitalizations trended towards larger improvements in
the ACT+TAU condition than the TAU condition (See Figure 2).
Hypothesis 3: For AN patients, pre‐treatment weight would moderate the effect of treatment
condition, such that the advantage of ACT+TAU will be more pronounced among those with lower
weights at pre‐treatment.
A regression analysis was conducted in patients with AN spectrum disorders using weight at
baseline, condition, and the interaction between condition and baseline weight (centered at a mean of
103.04 pounds) as the IVs and EDE global score at post‐treatment as the DV. All terms were entered
simultaneously. A trend was observed such that individuals with lower starting weights did better in the
ACT+TAU condition (B=.32, S.E.=.18, p=.09). Exploratory analyses were conducted with BN spectrum
patients to assess whether starting weight interacted with treatment condition to predict post‐
treatment EDE global scores. No significant interaction was observed among BN spectrum patients
(B=.006, S.E.=.04, p=.88).
The aim of this study was to test whether patients with more severe symptomatology at pre‐
treatment experienced greater improvements in eating disordered behavior when receiving an ACT‐
based treatment plus treatment‐as‐usual than treatment‐as‐usual alone in a residential eating disorder
treatment facility. Consistent with hypotheses, participants with higher baseline pathology trended
towards experiencing less severe symptoms at post‐treatment in the ACT+TAU condition compared to
those receiving only TAU. A similar pattern was seen for patients with prior hospitalizations for eating
pathology, although again results were at the trend level. Effect sizes were small, though this is
unsurprising given the small relative dose of ACT in the context of the residential treatment program.
Additionally, AN patients with lower body weights had better treatment outcome at the trend level in
the ACT+TAU condition. Together, these results supplement the prior study by Juarascio and colleagues
that suggested ACT may be an effective treatment for eating disorders (Juarascio et al., 2013), by
showing that ACT may be particularly powerful for patients with more severe symptomatology and
treatment refractory eating pathology. The strategies in an ACT‐based treatment, such as increasing
psychological flexibility and willingness to experience discomfort, may help more severe patients
increase their ability to tolerate the distress caused by treatment (e.g. gaining weight, refraining from
compensatory behaviors that ease distress in the short term) and enhance willingness to engage with
treatment more fully.
This study is one of the first to examine whether some individuals with eating disorders are
more likely to benefit from ACT. A major strength of this study was the use of a full clinical eating
disorder sample and a relatively large sample size. Despite the strengths of the study, a number of
limitations also exist. Because the study is a post‐hoc analysis of a pre‐existing database, it was not
sufficiently powered for the current analyses. The post‐hoc design also limited the types of severity
measures to those used in the original study. All patients were receiving a full residential program and
the ACT condition received only a small dose of the experimental treatment in addition to the
comprehensive treatment package, which may potentially have diluted the effects of the ACT groups.
Additionally, using an existing residential facility as a research site limited the ability to enact a number
of research controls that would have improved the study design such as randomization to treatment
The findings of the current study suggest that ACT may be an effective treatment for eating
disorders and a viable treatment option for individuals with more severe symptomatology. However, the
research on ACT for eating disorders remains in its infancy. Further research identifying who most will
benefit from this type of treatment approach is warranted.
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Acceptance and Commitment Therapy may be an effective therapy for eating disorders.
The study assessed whether more severe eating pathology moderated the effect of ACT.
Severity of self‐reported eating pathology moderated treatment effects.
More severe pathology made greater gains in ACT than in treatment‐as‐usual.
Similar patterns were found for previous hospitalizations and low weight in AN.