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Acceptance and Commitment Therapy Versus Cognitive Therapy for the Treatment of Comorbid Eating Pathology

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Previous research has indicated that although eating pathology is prevalent in college populations, both CBT and non-CBT-based therapies achieve only limited effectiveness. The current study examined several questions related to the treatment of eating pathology within the context of a larger randomized controlled trial that compared standard CBT (i.e., Beck's cognitive therapy; CT) with acceptance and commitment therapy (ACT; Hayes, 2004).The results indicated that the two treatments were differentially effective at reducing eating pathology. Specifically, CT produced modest decreases in eating pathology whereas ACT produced large decreases. In addition, a weaker suggestion emerged that ACT was more effective than CT at increasing clinician-rated global functioning among those with eating pathology. These findings suggest that ACT is a useful treatment for disordered eating and potentially, for eating disorders per se.
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Behavior Modification
DOI: 10.1177/0145445510363472
2010; 34; 175 Behav Modif
Adrienne S. Juarascio, Evan M. Forman and James D. Herbert
for the Treatment of Comorbid Eating Pathology
Acceptance and Commitment Therapy Versus Cognitive Therapy
http://bmo.sagepub.com/cgi/content/abstract/34/2/175
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Behavior Modification
34(2) 175 –190
© 2010 SAGE Publications
DOI: 10.1177/0145445510363472
http://bmo.sagepub.com
Acceptance and
Commitment
Therapy Versus
Cognitive Therapy
for the Treatment
of Comorbid Eating
Pathology
Adrienne S. Juarascio,1 Evan M. Forman,1
and James D. Herbert1
Abstract
Previous research has indicated that although eating pathology is prevalent
in college populations, both CBT and non-CBT-based therapies achieve
only limited effectiveness. The current study examined several questions
related to the treatment of eating pathology within the context of a larger
randomized controlled trial that compared standard CBT (i.e., Beck’s
cognitive therapy; CT) with acceptance and commitment therapy (ACT;
Hayes, 2004). The results indicated that the two treatments were differentially
effective at reducing eating pathology. Specifically, CT produced modest
decreases in eating pathology whereas ACT produced large decreases.
In addition, a weaker suggestion emerged that ACT was more effective
than CT at increasing clinician-rated global functioning among those with
eating pathology. These findings suggest that ACT is a useful treatment for
disordered eating and potentially, for eating disorders per se.
1Drexel University, Philadelphia, PA
Corresponding Author:
Evan M. Forman, Department of Psychology, Drexel University, 245 N. 15th Street,
MS 515, Philadelphia, PA 19102
Email: evan.forman@drexel.edu
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176 Behavior Modification 34(2)
Keywords
ACT, CBT, eating disorders
Cognitive Therapy
Cognitive behavioral treatment (CBT) for eating disorders is currently con-
sidered to be the most effective treatment for eating disorders, especially for
bulimia (National Institute for Clinical Excellence; NICE, 2004). CBT refers
to a broad array of related treatment approaches, with the most utilized and
best-researched falling under the broad rubric of Beckian cognitive therapy
(CT; Beck, 1970; Forman & Herbert, 2009). Modified CT is currently con-
sidered the treatment of choice for individuals with an eating disorder. In a
standard course of CT for an individual who presents with bulimia, the
patient undergoes 20 treatment sessions with a focus on three major stages
(Fairburn, Marcus, & Wilson, 1993). The main goals include normalization
of eating, reducing attempts to diet, eliminating binge eating and purging,
and altering beliefs, thoughts, and values which maintain the eating problem.
The same protocol can be used for those suffering from anorexia with only
minor variations and typically an extended time frame.
Research to date has shown that CT is a useful treatment for bulimia
(Wilson, Grilo, & Vitousek, 2007) and it has currently been given a grade of
A by the National Institute for Clinical Effectiveness Guidelines, indicating
it is the treatment of choice for this disorder (NICE, 2004) . The treatment has
been found to produce significant reductions in the frequency of binge eating,
purging, and other compensatory behaviors (such as use of laxatives, diuret-
ics, and fasting) used by bulimics to control their weight (Fairburn, 2008;
Treasure et al., 1994). CT has been found to produce rapid changes in the
eating patterns of individuals with bulimia nervosa, and its effects have also
been found to be well maintained over time (Waller et al., 1996). However a
relatively large subset of individuals who present for treatment do not achieve
clinically significant benefit, with some studies showing only 30-50% of
patients ceasing to binge and purge (Fairburn 2008; Wilson, 2005; Wilson
et al., 2007). In the case of anorexia, brief manualized CT has been shown to
have little effect on eating pathology (though studies have typically been
small, poorly designed, and certainly need further replication; Wilson, 2005).
In sum, although CT has been shown to result in statistically significant
reductions in eating pathology, the percentage of patients who fully remit
from the disorder leave room for improvement.
Despite the fact that CT is the current gold standard for the treatment of
bulimia, there is a number of reasons it might not be best suited to treat this
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Juarascio et al. 177
type of disorder. First, patients with eating pathology (particularly those with
anorexia) often have little desire to change, particularly when their disor-
dered eating has (or is believed to have) helped them lose substantial amounts
of weight and they are now closer to the thin ideal (Vanderlinden, 2008).They
may thus be reluctant to engage in any treatment with a direct agenda to
modify eating behavior. Secondly, CT directly attempts to change the content
of maladaptive eating-related cognitions (Vanderlinden, 2008). However, the
egosyntonic nature of eating disorder cognitions may make them particularly
resistant to direct modification efforts (Guarda, 2008). In addition, many
unhealthy eating behaviors are functional within the context of the patient’s
belief system. For instance, if someone believes that she weighs too much
and wishes to lose weight, intense dieting or purging behaviors may in fact
help her decrease her weight, at least temporarily.
Rather than attempting to modify the content of cognitions about weight
and body image, it could be beneficial to focus on changing how the indi-
vidual interacts with her thoughts and feelings. Acceptance of distressing
thoughts could be particularly useful for individuals with an eating disorder
because many of their distressing thoughts might be true, and therefore dif-
ficult to change. For example, thoughts about the imperfect nature of one’s
body are likely true and therefore not an appropriate type of thought to
restructure. Instead, the patient could benefit from becoming more accepting
of her thoughts about her imperfections, and therefore more likely to resist
engaging in behaviors designed to eliminate such thoughts. This acceptance
would allow the patient to be nonjudgmentally aware of her distressing
thoughts, but better able to sit with the thoughts and not engage in eating
disordered symptoms as a means of making the thoughts stop.
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) rests on the premise that a patient’s
reaction to a thought or feeling is changeable, but that the internal experience
itself is not (Hayes, Strosahl, & Wilson, 1999). ACT seeks to teach clients
how to become more accepting of distressing cognitions and feelings because
attempting to control unwanted experiences is often ineffective if not coun-
terproductive (Hayes, 2004). A treatment protocol of ACT for eating disorders
has been developed and applied (Heffner, Sperry, Eifert, & Detweiler, 2002).
The first step is to elicit a sense of creative hopelessness, by demonstrating
that previous strategies to reduce feelings of body image dissatisfaction,
including the use of compensatory strategies or extreme dieting, have not
been effective (Hayes, 2004). For example, the therapist might point out that
although the patient may have lost a great deal of weight, she is still just as
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178 Behavior Modification 34(2)
concerned about being overweight. Patients are shown that struggling or
trying to control distressing feelings can create additional distress and the
most workable solution (which eventually provides more freedom and
behavioral flexibility) is to adopt an attitude of acceptance. Clarification of
the patient’s individual values and goals are a large focus throughout treat-
ment. Values provide the context for specific treatment targets, and dignify
the difficult work involved in increasing mindful acceptance of distressing
experiences. Patients are taught that distress tolerance is not an end in and of
itself, but rather a means to the end of engaging in valued behaviors. Addi-
tionally, it is important to realize that at its roots, ACT is a type of behavior
therapy, and therefore standard behavioral approaches to eating disorders
(e.g., exposure, self-monitoring) can be integrated within the treatment.
There are conceptual reasons why ACT might be especially effective for
those with disordered eating. Previous research has suggested that higher
baseline levels of mindfulness and acceptance, two central components of
ACT, are associated with better treatment outcome in eating disorders (Baer,
Fischer, & Huss, 2005; Kristeller, Baer, & Quillian-Wolever, 2006; Sandoz,
Wilson, Merwin, in press). In addition, ACT might be well suited for eating
disorders because of its focus on reducing cognitive control. Problematic
desire for control over distressing thoughts is theorized to be a central feature
in eating disorders (Tiggemann & Raven, 1998). For example, it is not uncom-
mon for individuals with an eating disorder to try to avoid thoughts about their
weight or shape by restricting their food intact, over exercising, or taking laxa-
tives or diuretics. These behaviors can temporarily help to reduce concerns
about weight or shape; however, the thoughts and feelings tend to return. ACT
encourages patients to stop the (counterproductive) struggle with unpleasant
thoughts or feelings and to decrease attempts to avoid or alter these internal
experiences.
Another reason that ACT might be particularly useful for the treatment of
eating pathology relates to the low motivation to change characteristic of most
individuals with anorexia and many with bulimia. Lack of motivation likely
relates to the fact that these individuals narrowly view their life objectives as
centered around eating and appearance, and view their restricting/purging
behaviors as necessary to meet these objectives. Although CBT for eating
disorders does attempt to increase motivation in these patients, ACT may be
particularly useful in this regard due to its focus on values. One of ACT’s
prime foci is on identifying and clarifying individuals’ ultimate life values. By
helping identify core values and the broader goals emanating from them, ACT
helps the patient not only reorient toward more meaningful activities but to
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Juarascio et al. 179
become more willing to tolerate internal discomfort for the sake of what is
truly important.
Subclinical Eating Pathology
Most of the research on the treatment of disordered eating has been con-
ducted among the samples who meet full criteria for an eating disorder.
However, a much bigger group of individuals exists who do not have a frank
eating disorder, but still suffer from serious cognitive, affective, and behav-
ioral eating-related symptoms, for example, intensely negative body image,
obsessive thinking about food, and appearance, nutritional restriction, bing-
ing, purging (Fairburn & Bohn, 2005). In fact, large group of individuals
with subclinical eating pathology and the debilitating nature of their symp-
toms has led many eating disorder experts to argue that eating disorder
diagnosis should occur on a dimensional rather than a categorical system,
and to advocate increased study of subclinical eating pathology (Lewinsohn,
Striegel-Moore, & Seeley, 2000).
Research has indicated that a large number of women regularly engage in
behaviors that can be classified as subclinical eating pathology (Mulholland &
Mintz, 2001). Previous studies have indicated that up to 60% of college women
report either occasionally or regularly using unhealthy measures such as fast-
ing, diuretics, appetite suppressants, or purging as a means of controlling their
weight (Mintz & Betz, 1986). Research has indicated that in many cases, indi-
viduals with subclinical eating pathology do not differ significantly from those
receiving a diagnosis of anorexia nervosa or bulimia nervosa in terms of how
distressing the symptoms can be and how they affect quality of life (Fairburn
& Bohn, 2005). The study of interventions for subclinical eating pathology is
especially important. Early intervention is thought to reduce the likelihood that
an individual with subclinical eating pathology will develop a clinical eating
disorder and can help to improve quality of life (Ratnasuriya, Eisler,& Szmuk-
ler, 1991), and the prevention of disorders before they become fully realized is
known to be a more efficient intervention strategy (Institute of Medicine,
1998). However, little is currently known about which interventions are most
effective for treating subclinical eating pathology or for preventing frank eating
disorders (le Grange & Loeb, 2007).
Current Study
The present study aimed to investigate the relative effectiveness of ACT and
CT in ameliorating subclinical eating pathology. Given the theoretical match
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180 Behavior Modification 34(2)
between ACT and the treatment of eating disorders, it was hypothesized that
ACT would be more effective at reducing eating pathology. It was also
hypothesized that the advantage of ACT over CT would generalize to non-
bearing disordered outcomes, as the improvement in eating pathology would
lead to improvements in overall functioning. Determining which treatment
results in greater improvement in overall quality of life for those with eating
pathology could help clinicians better select which treatment to use with cli-
ents who have comorbid eating pathology. The current study evaluated these
hypotheses in a sample of post-baccalaureate students who took part in a
larger study of the relative effectiveness of ACT and CT. Specifically, the
study examined a subsample who presented with subclinical eating pathol-
ogy at intake. Although not equivalent to a sample of individuals with frank
eating disorders, the study allows for a post hoc test of the relative efficacy of
two therapeutic interventions in reducing subclinical eating pathology.
Results of this test could both identify effective treatments for a population
with subclinical eating pathology and inform future research on treatments
for diagnosable eating disorder.
Method
Participants
Participants presented for treatment at a university student-counseling center
(SCC) that serves a diverse group of individuals pursuing post-baccalaureate
health-related degrees and certifications. Inclusion criteria were kept broad
to maximize external validity. Thus, all those presenting for individual psy-
chotherapy were deemed eligible unless they exhibited psychotic symptoms.
Individuals presenting for couples or family therapy, or who requested study
skills training or crisis intervention were excluded. A total of 220 participants
met baseline criteria for the larger study. From this group 31 individuals were
dropped out before randomization and therefore were not included in further
analyses. Additional information as to the sample or participant recruitment
strategies can be found in the initial article from this data-set (Forman, Herbert,
Moitra, Yeomans, & Geller, 2007).
Degree of eating pathology was assessed both by examining those who
met diagnostic criteria for an eating disorder and by obtaining the frequency
of those reporting eating pathology. Results indicated that the proportion of
participants (4%) who were formally diagnosed with an eating disorder was
low, and somewhat lower than traditional college undergraduate populations,
which this sample was not. The diagnoses included four individuals with
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Juarascio et al. 181
bulimia, two with anorexia, and one with an eating disorder not otherwise
specified. However, a large proportion (i.e., 39% total, 43% of women, 16%
of men) of the sample evidenced subclinical eating pathology. These 39%
(N = 55) were included in the main analyses. Women constituted the larger
portion of the remaining sample (92.6%). The participants’ mean age was
26.00 years (SD = 5.71; range = 19-46), 53% of the sample was single (27%
living with partner or spouse), and 71% were Whites (5% Black, 13% Asian,
and 2% Latino). Of the 55 individuals with eating pathology, 49.1% had an
anxiety disorder, 29.2% had a depressive disorder, and 11.1% had an adjust-
ment disorder as their primary diagnosis.
Measures
Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996). The
BDI-II is an extensively used and studied inventory designed to assess cur-
rent severity of depressive symptoms. Attitudes and symptoms consistent
with depression are represented in a 21-item questionnaire, and patients are
asked to rate the severity of each on an ordinal scale ranging from 0 to 3. This
measure has demonstrated good reliability and validity in clinical samples
(Beck, Steer, & Garbin, 1988).
Beck Anxiety Inventory (BAI; Beck et al., 1988). The BAI is the most widely
used instrument for assessing anxious symptoms. It is a self-report measure
that reliably differentiates anxious from nonanxious groups in a variety of
clinical populations and discriminates anxiety from depression. The scale
consists of 21 items, including physiological and cognitive features of anxi-
ety. Participants are asked to rate how much they have been bothered by each
symptom over the past week on a 4-point scale ranging from 0 to 3. The BAI
has demonstrated strong validity and good reliability in clinical samples
(Beck et al., 1988).
Global assessment of functioning scale (GAF; APA, 2000). The GAF score is
outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th
ed., Text Revision) (DSM-IV-TR) as the Axis V assessment of overall func-
tioning. This score is utilized by the clinician to report his or her assessment
of the patient’s overall level of functioning. This information is used to
plan treatment as well as to measure its effects. The GAF ranges from 1 (per-
sistent danger of hurting oneself or others) to 100 (superior functioning),
with levels of functioning divided into 10-point ranges.
Quality of life index (QOLI; Frisch, Cornell, Villanueva, & Retzlaff, 1992).
The QOLI is a measure of life satisfaction rooted in the view that overall life
quality is the sum of satisfaction in a variety of life domains. Respondents
182 Behavior Modification 34(2)
rate the importance of a variety of life domains on a scale ranging from 0 (not
important) to 2 (extremely important) as well as their satisfaction with these
life domains on a scale from −3 (very dissatisfied) to 3 (very satisfied). Test–
retest reliability for the QOLI was strong (range of .80 to .91), and internal
consistency was high (range of .77 to .89) across three clinical and three
nonclinical samples (Frisch et al., 1992).
Eating pathology index (EPI). The EPI was adapted from the SCOFF, a mea-
sure designed as a brief 5-item screen for the presence of disordered eating
(Morgan, Reid, & Lacey, 1999). Specfically, participants were asked “In the
past week did you”: (a) Believe yourself to be fat when others say you are too
thin, (b) Worry you have lost control over how much you eat, (c) Say that food
dominates your life, (d) Make yourself throw up, (e) Constantly worry about
gaining weight. An answer of “yes” on each question receives one point, with
a score of greater than or equal to 2 points indicating a likely case of anorexia
or bulimia (Morgan et al., 1999). Therefore, for the present study, a score of
greater than or equal to one point was used as an inclusion criteria to obtain
patients with either clinical or subclinical eating pathology. Psychometric data
on the SCOFF indicate that it is an acceptable screen in terms of sensitivity and
specificity (Cotton, Ball, & Robinson, 2003; Morgan et al., 1999). Correlations
between ED diagnosis and scores on the EPI were significant (r = .20, p < .01).
Procedure
After agreeing to participate in the study, consenting patients were randomly
assigned to either the CT or the ACT treatment condition. Because the origi-
nal study was designed to measure the effectiveness of CT and ACT, the
therapists did not use specific treatment manuals, but were instead taught to
employ core aspects of the treatment when refraining from cross-contamination.
Although the two therapies shared a great deal of nonspecific factors and
employed similar behavioral techniques, certain aspects were deemed to be
unique to one condition. For example, in the CT condition core aspects were
considered to be the discussion of automatic thoughts, core beliefs, and sche-
mas; identification of cognitive distortions; cognitive disputation; and
cognitive restructuring (Forman et al., 2007). Core aspects of the ACT con-
dition included discussions of experiential acceptance and willingness,
mindfulness training, values clarification, distress tolerance, and the differ-
ences between “clean” and “dirty” distress. See Forman et al. (2007) for a
more thorough discussion of the content of both the CT and ACT conditions,
as well as the training procedures. To replicate real-world conditions partici-
pants and therapists mutually established duration or time of termination.
Juarascio et al. 183
At baseline, therapists conducted semi-structured interviews using the
Mini International Neuropsychiatric Interview (Sheehan et al. 1997), based on
the DSM-IV-TR(American Psychiatric Association, 1994). Also, at baseline
and at termination, participants completed a questionnaire packet containing
self-report measures of outcome and process variables. Therapists reported
on their impressions of participants’ global functioning on this same sched-
ule. All therapists (n = 23) conducted both treatments. Therapists were
doctoral psychology students in a CBT-oriented clinical psychology program
who received training in both ACT and CT. To ensure treatment fidelity,
independent raters coded 2-3 audio recordings of sessions for each study
participant using a specially-developed, validated adherence, and compe-
tence measure (For more information about treatment conditions, treatment
fidelity and competence, therapist allegiance, and participant expectancies
see Forman et al., 2007).
It is important to note that although eating pathology was listed as a pre-
senting complaint by all patients, the extent to which the eating pathology
concerns were a focus of treatment varied by patient. Moreover, given the
post hoc nature of the present study design, the exact degree to which these
concerns were a focus of treatment is not known, thereby precluding its
examination as a potential moderator of treatment efficacy.
Results
The 55 participants who demonstrated eating pathology and attended at least
one treatment session were equally distributed between the two treatment
conditions (ACT = 27, CT = 28). The total mean number of sessions
that these participants attended was 12.70 (SD = 12.38), and was equivalent
between treatment groups (t[53] = –1.11, p = .27). The ACT and CT group
were also equivalent on all demographic and outcome measures at baseline
(see Table 1). To be conservative about the effects of treatment, an intention-
to-treat strategy was utilized. Specifically, the baseline data from participants
(n = 3, ACT; n = 4, CT) who dropped out of the study before completing post-
treatment measures were carried forward. However, to assess the effect of
receiving a full dose of treatment, additional analyses using only the 48 treat-
ment completers (n = 24, ACT; n = 24, CT) were also conducted.
A mixed (two assessment occasions by two groups) repeated-measures
analysis of variance (ANOVA) was conducted to determine the extent to
which eating pathology decreased between baseline and post-treatment and
whether this decrease was moderated by treatment group. Both the time
main effect (F[1, 53] = 16.90, p < .01, partial h2 =.24) and the group by time
184 Behavior Modification 34(2)
interaction (F[1, 53] = 4.71, p =.03, partial h2 = .08) were significant. Spe-
cifically, results indicated a slight decrease in eating pathology across time
for the CT group, but a significantly steeper decrease in eating pathology
between baseline and post-treatment in the ACT group (Figure 1). To ensure
that the results were not attributable to a gender confound (female partici-
pants reporting higher eating pathology), the repeated measures ANOVA was
repeated controlling for gender, and similar results were obtained. These
results, in combination with effect size calculations, suggest that CT (Cohen’s
d = 0.48) had only a relatively modest effect on eating pathology, whereas
ACT (d = 1.89) effected a very large decrease in eating pathology. A similar
interaction pattern was observed when using only treatment completers in the
analysis (F[1, 46] = 18.51, p < .05, partial h2 =.11), with the ACT group again
showing a significantly steeper decrease in eating pathology between base-
line and post-treatment.
To examine whether ACT or CT was better at reducing noneating outcome
variables for those with eating pathology, a series of repeated measures
ANOVAs were conducted. Each ANOVA used eating pathology at baseline
(i.e., high vs. medium vs. low on the eating pathology index), treatment group
(CT vs. ACT), and time (pre vs. post-treatment) as independent variables. The
dependent variables included the various noneating related outcome mea-
sures (e.g., GAF, BDI, BAI, and QOLI). The time by condition by eating
pathology interaction was not significant for BDI (F[3, 46] = .28, p =.84,
partial h2 =.02), BAI (F[3, 46] = .30, p = .82, partial h2 =.02), or QOLI
Table 1. Baseline Characteristics of Sample
CTa ACTb
Variable M SD M SD t
Age 26.39 6.65 25.58 4.57 .52
GAF 64.25 11.73 65.04 9.24 –.27
BDI 19.96 10.95 20.44 11.87 –.15
BHS 6.40 5.20 7.69 6.56 –.81
BAI 14.78 11.50 16.50 10.63 –.58
QOLItotal 0.65 2.29 1.09 2.03 –.62
EATtotal 2.42 1.23 2.14 1.02 .92
Note: GAF = global assessment of functioning scale; BDI = Beck Depression Inventory;
BHS = Beck Hopelessness Scale; BAI = Beck Anxiety Inventory; QOLI = Quality of life index;
EAT = Eating pathology index.
a. (N = 27).
b. (N = 28).
Juarascio et al. 185
(F[3, 46] = .93, p = .44, partial h2 = .09), indicating that eating pathology did
not moderate the efficacy of the conditions at improving overall functioning
as measured by these domains. However, a strong trend was found for a
3-way interaction between GAF scores, condition, and time (F[3, 46] = 2.43,
p =.07, partial h2 =.15), with those in the ACT condition showing greater
gains in GAF but only for those with more severe eating pathology.
Discussion
Given the treatment-resistant nature of eating pathology, as well as the lim-
ited effectiveness of standard CT for the treatment of eating pathology,
alternative treatments should be investigated. The current study compared
the effectiveness of CT and ACT for the treatment of eating pathology. ACT
(pre to post-treatment Cohen’s d = 1.89) was shown to be superior to CT
(d = 0.48) at reducing problem eating behavior. Although ACT and CT share
many of the same nonspecific therapeutic effects and utilized similar behav-
ioral techniques, there are several ways in which they differ. This study
reinforces previous studies that suggested that core strategies of ACT, that is,
Figure 1. Interaction between group and time in predicting eating pathology
186 Behavior Modification 34(2)
increasing acceptance, mindfulness, willingness, and distress tolerance, may
be useful ways to promote change in a population with eating symptomotol-
ogy (Baer, Fischer, & Huss, 2005; Kristeller et al., 2006; Sandoz et al., in
press). The fact that minimal change in eating pathology occurred between
baseline and post-treatment for those in the CT condition raises the possibil-
ity that core aspects of CT (e.g., identifying automatic thoughts and cognitive
distortions, engaging in cognitive disputation and restructuring) may be less
effective for this population. Although future research is sorely needed, these
results suggest that an acceptance-based version of CBT could be an effec-
tive treatment for individuals with eating pathology.
Another reason that ACT may have been especially effective is that it
more explicitly addresses the motivational issues commonly associated with
eating pathology. One way that ACT might increase patients’ motivation to
engage in treatment is by clarifying goals and values that are bound up in,
and obscured by, the eating disorder. By helping patients better understand
and work toward values unconnected with body shape, food or weight, ACT
may facilitate a desire for change and ultimately lead patients to become less
resistant to treatment. Given that many patients with eating pathology have
little interest in change, it is not surprising that these individuals are noto-
riously resistant to treatment, including state-of-the-art CT. Although these
results are promising, future investigation is needed to determine the spe-
cific treatment components (e.g., increased motivation, values clarification)
responsible for therapeutic effects.
There are several strengths and weaknesses associated with the present
study that are worth noting. First, for a randomized controlled trial of two
active treatments, the sample size of participants was relatively large. The
additional power gained from such a sample size allows for greater confi-
dence in the results. Also, few exclusion criteria were used for the study and
treatments, though specified, were not manualized. Thus, both the sample
and the treatments were highly representative and externally valid.
One important limitation is that the focus of the study was subclinical
eating pathology; thus, findings may not generalize to patients with eating
disorders per se and the extant literature that mainly focuses on clinical eating
disorders. However, given the relatively low number of individuals who have
a diagnosable eating disorder, the lack of motivation for treatment in this pop-
ulation, and the high treatment dropout rates, it can be difficult to conduct
large randomized trials among the patients with eating disorders. One solution
to this problem is to test possible treatments among the samples that have
substantial eating pathology, but do not meet criteria for an eating disorder, as
these patients are both more frequently encountered and may be more likely
to remain in treatment. Because this population exhibit a similar set of cognitions
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Juarascio et al. 187
and behaviors, and demonstrate clinical impairment in functioning, pilot test-
ing of novel treatments for eating disorders could be done in this group before
utilizing the considerable resources it takes to conduct research in a sample
with clinical eating disorders. This can help to provide preliminary evidence
for treatments that could effectively treat eating disorders, before the substan-
tial investigative burden is undertaken. In addition, research on the treatment
of eating pathology more broadly is an important contribution to the literature,
given the large numbers who demonstrate some degree of eating pathology,
and the extent to which this subclinical pathology can reduce quality of life
(Mulholland & Mintz, 2001).
Another limitation is that only a relatively simplistic measure of eating
pathology was available for the current study. However, the questions in this
measure were heavily based on a validated measure of eating pathology (the
SCOFF), and the EPI was significantly correlated with an eating disorder
diagnosis. The relatively low association between the EPI and eating disorder
diagnosis is not necessarily of surprise or of concern given (a) the very small
number of patients in this sample with an eating disorder diagnosis, (b) the
likelihood of missed eating disorder diagnosis due to the fact that a structured
diagnostic tool was not employed, and (c) the inclusive nature of the EPI,
which was designed to capture moderate levels of eating pathology and body
image dissatisfaction. In any case, these findings should be replicated using
a sample with more severe eating pathology and as assessed by a stronger
measure of eating pathology.
Lastly, this study was unable to measure the degree to which eating pathol-
ogy was a focus of treatment, and the two types of treatment did not target
eating pathology unless a patient acknowledged that eating pathology was a
concern. Similarly, the extent to which the CT (or ACT) condition resembled
dedicated CBT for eating disorders varied depending on the extent to which
eating pathology was the core concern. In some cases the patient would have
received a more generic form of CT focused on addressing anxiety and
depressive symptoms and related behaviors. Thus, results might be different
among patients whose eating-related symptoms were their primary complaint
and who received a specific eating disorder protocols. Future research is
called for that would compare ACT and CT protocols for eating pathology
and/or eating disorders.
Although traditional CBT (i.e., CT) is currently the gold standard of treat-
ment for eating disorders, previous work demonstrates that more than half of
the individuals with bulimia are still bingeing and purging post-treatment,
and its efficacy has not been well establish among those with anorexia. Cur-
rent findings indicate that an acceptance-based version of CBT (i.e., ACT)
was more effective than CT in treating eating pathology. The current study
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188 Behavior Modification 34(2)
thus raises the possibility that an acceptance-based CBT may be an effective
treatment for eating concerns, but much more research is needed to replicate
and refine these early findings. In addition, future research could investigate
the preliminary evidence suggesting that ACT may be better at improving
overall functioning in participants with eating pathology. Given the promis-
ing results for the treatment of subclinical eating pathology, research using
ACT with patients who have an eating disorder could help to determine
whether this could be a viable and effective treatment for a population where
previous treatment has had limited success.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect to the authorship
and/or publication of this article.
Funding
The authors received no financial support for the research and/or authorship of this
article.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of men-
tal disorders (4th ed., text rev.). Washington, DC: Author.
Baer, R. A., Fischer, S., & Huss, D. B. (2005). Mindfulness and acceptance in the
treatment of disordered eating. Journal of Rational-Emotive & Cognitive Behav-
ior Therapy, 23, 281-300.
Beck, A. T. (1970). Cognitive therapy: Nature and relation to behavior therapy.
Behavior Therapy, 1, 184-200.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression
Inventory-II. San Antonio, TX: Psychological Corporation.
Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the
beck depression inventory: Twenty-five years of evaluation. Clinical Psychology
Review, 8, 77-100.
Cotton, M., Ball, C., & Robinson, P. (2003). Four simple questions can help screen for
eating disorders. Journal of General Internal Medicine, 18, 53-56.
Fairburn, C. G. (2008). Eating disorders: The transdiagnostic view and the cognitive
behavioral theory. In C. G. Fairburn (Ed.), Cognitive behavior therapy and eating
disorders. (pp. 7-22). New York: Guilford.
Fairburn, C. G., & Bohn, K. (2005). Eating disorder NOS (EDNOS): An example of
the troublesome “not otherwise specified” (NOS) category in DSM-IV. Behaviour
Research and Therapy, 43, 691-701.
at DREXEL UNIV LIBRARIES on May 9, 2010 http://bmo.sagepub.comDownloaded from
Juarascio et al. 189
Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral
therapy for binge eating and bulimia nervosa: A comprehensive treatment manual.
In C. G. Fairburn, & G. T. Wilson (Eds.), Binge eating: Nature, assessment, and
treatment (pp. 361-404). New York: Guilford.
Forman, E. M., & Herbert, J. D. (2009). New directions in cognitive behavior therapy:
Acceptance-based therapies. In W. O’Donohue & J. E. Fisher, (Eds.), General
principles and empirically supported techniques of cognitive behavior therapy
(pp. 77-101). Hoboken, NJ: Wiley.
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A ran-
domized controlled effectiveness trial of acceptance and commitment therapy and
cognitive therapy for anxiety and depression. Behavior Modification, 31, 772-799.
Frisch, M. B., Cornell, J., Villanueva, M., & Retzlaff, P. J. (1992). Clinical validation
of the Quality of Life Inventory: A measure of life satisfaction for use in treatment
planning and outcome assessment. Psychological Assessment: Journal of Consult-
ing and Clinical Psychology, 4, 92-101.
Guarda, A. S. (2008). Treatment of anorexia nervosa: Insights and obstacles. Physiol-
ogy & Behavior, 94, 113-120.
Hayes, S.C. (2004). Acceptance and commitment therapy, relational frame theory,
and the third wave of behavior therapy. Behavior Therapy, 35, 639-665.
Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment
therapy: An experiential approach to behavior change. New York: Guilford.
Heffner, M., Sperry, J., Eifert, G. H., & Detweiler, M. (2002). Acceptance and com-
mitment therapy in the treatment of an adolescent female with anorexia nervosa:
A case example. Cognitive and Behavioral Practice, 9, 232-236.
Institute of Medicine. (1998). The Future of Public Health. Washington, DC: National
Academy Press.
Kristeller, J., Baer, R., & Quillian-Wolever, R. (2006). Mindfulness-based approaches
to eating disorders. In R. A. Baer (Ed.). Mindfulness-based treatment approaches
(pp. 75-91). San Diego: Elsevier.
le Grange, D., & Loeb, K. L. (2007). Early identification and treatment of eating
disorders: Prodrome to syndrome. Early Intervention in Psychiatry, 1, 27-39.
Lewinsohn, P. M., Striegel-Moore, R. H., & Seeley, J. H. (2000). Epidemiology and
natural course of eating disorders in young women from adolescence to young
adulthood. Journal of the American Academy of Child & Adolescent Psychiatry,
39, 1284-1292.
Mintz, L. B., & Betz, N. E. (1986). Sex-differences in the nature, realm, and correlates
of body image. Sex Roles, 15, 185-195.
Morgan, J. F., Reid, F., & Lacey, J. H. (1999). The SCOFF questionnaire: assessment of
a new screening tool for eating disorders. British Medical Journal, 319, 1467-1468.
at DREXEL UNIV LIBRARIES on May 9, 2010 http://bmo.sagepub.comDownloaded from
190 Behavior Modification 34(2)
Mulholland, A. M., & Mintz, L. B. (2001). Prevalence of eating disorders among
African American women. Journal of Counseling Psychology, 48, 111-116.
National Institute for Clinical Excellence (NICE). (2004). Eating disorders—Core
interventions in the treatment and management of anorexia nervosa, bulimia
nervosa and related eating disorders (Clinical Guideline No. 9). London: Author.
Available from www.nice.org.uk/guidance/CG9
Ratnasuriya, R., Eisler, I., & Szmukler, G. I. (1991). Anorexia nervosa: Outcome and
prognostic factors after 20 years. British Journal of Psychiatry, 156, 495-456.
Sandoz, E. K., Wilson, K. G., & Merwin, R. M. (in press). Assessment of body image
acceptance: The Body Image—Acceptance and Action Questionnaire. Association
for Contextual Behavioral Science.
Sheehan D. V., Lecrubier Y., Harnett Sheehan K., et al. (1997). The validity of the
Mini International Neuropsychiatric Interview (MINI) according to the SCID-P
and its reliability. European Psychiatry, 12, 232-241.
Tiggemann, M., & Raven, M. (1998). Dimensions of control in bulimia and anorexia
nervosa: Internal control, desire for control, or fear of losing self-control? Eating
Disorders, the Journal of Treatment and Prevention, 6, 65-71.
Treasure, J., Schmidt, U., Troop, N., Tiller, J., Todd, G., Keilen, M., et al. (1994). First
step in managing bulimia nervosa: controlled trial of therapeutic manual. British
Medical Journal, 308, 686-689.
Vanderlinden, J. (2008). Many roads lead to Rome: Why does cognitive behavioural
therapy remain unsuccessful for many eating disorder patients? European Eating
Disorders Review, 16, 329-333.
Waller, D., Fairburn, C., McPherson, A., Kay, R., Lee, A., & Nowell, T. (1996). Treating
bulimia in primary care: A pilot study. International Journal of Eating Disorders,
19, 99-103.
Wilson, G. T. (2005). Psychological treatment of eating disorders. Annual Review of
Clinical Psychology, 1, 439-465.
Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eat-
ing disorders. American Psychologist.Special Issue: Eating Disorders, 62, 199-216.
at DREXEL UNIV LIBRARIES on May 9, 2010 http://bmo.sagepub.comDownloaded from
... Psychological flexibility results from the interaction of six core therapeutic processes: (a) Getting in contact with what is happening in the present moment, (b) learning to distance from a person's thoughts, (c) developing a more open attitude to and accepting painful internal experiences, including sensations, emotions, and thoughts, (d) contacting a stable sense of self, regardless of one's personal experiences, (e) clarifying values, conceptualizing chosen life directions, and (f) pursuing actions or stable behaviors driven by personal values [22]. ...
... Results showed that patients undergoing ACT-based group sessions showed a greater weight loss than those receiving CBT after 12 months of treatment and were more likely to maintain weight loss after a 1-year follow-up. ACT was also found to be significantly effective in addressing comorbid eating disorders [21,22]. By fostering self-regulation skills, ACT could be considered a valid alternative to CBT in promoting the adoption as well as the maintenance of a healthy lifestyle even in those individuals who tend to overeat in response to negative feelings, a phenomenon known as emotional eating, which is common in obesity and eating disorders related to obesity such as Binge Eating Disorder [18,23]. ...
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... This component specifically targets eating disorder related cognition using strategies from cognitive behavior therapy or acceptance and commitment therapy that both have empirical support (Fairburn, 2008;Juarascio et al., 2010Juarascio et al., , 2013Parling et al., 2016). All patients will receive education about dysfunctional thoughts and will work with the therapist to improve identification of dysfunctional thoughts. ...
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... The result suggests that ACT is a feasible treatment option for individuals with eating pathology. Juarascio, A. S., et al., (2010) tried to examine several questions related to the treatment of eating pathology within the context of a larger randomized controlled trial that compared standard CBT with ACT. The results indicated that the two treatments were differentially effective at reducing eating pathology. ...
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... The result suggests that ACT is a feasible treatment option for individuals with eating pathology. Juarascio, A. S., et al., (2010) tried to examine several questions related to the treatment of eating pathology within the context of a larger randomized controlled trial that compared standard CBT with ACT. The results indicated that the two treatments were differentially effective at reducing eating pathology. ...
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This study was the first to establish Diagnostic and Statistical Manual of Mental Disorders ( DSM—IV; American Psychiatric Association, 1994) prevalence rates for eating disorders by targeting an entire sample of African American college women. Participants were 413 African American women enrolled at a large, predominantly Caucasian public university in the midwestern United States. Participants were given the Questionnaire for Eating Disorder Diagnoses (L. B. Mintz, M. S. O'Halloran, A. M. Mulholland, & P. A. Schneider, 1997). No respondents were classified as having anorexia nervosa or bulimia nervosa, and 2% were classified as having an eating disorder not otherwise specified. Twenty-three percent were classified as symptomatic. Although there is some evidence that these prevalence rates may be underestimated, they are nevertheless in the same range as those obtained for comparative Caucasian samples. Implications for future research and practice are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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(from the chapter) A new breed of cognitive behavior therapy (CBT), sometimes referred to as "acceptance-based" or "mindfulness-based" therapies, has gained increasing notoriety in recent years. The term acceptance refers to psychological acceptance of aversive internal experiences, that is, an openness to experiencing distressing thoughts, images, feelings and sensations without attempts to diminish or avoid them (Cordova, 2001; Hayes, Bissett et al., 1999). Hayes, the developer of one such therapy known as acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), has argued that these approaches are qualitatively distinct from other, more standard forms of CBT such that they form a new generation of therapies (Hayes, 2004b). A number of scholars associated with both acceptance-based therapies (e.g., Marsha Linehan and Adrienne Wells) and more traditional CBT (e.g., A T. Beck, Michelle Craske, Albert Ellis, Stefan Hofmann) disagree with Hayes's assessment (Arch & Craske, in press; Ellis, 2000,2005; Hofmann & Asmundson, 2008; Linehan, personal communication, April 16, 2008), and view these new developments as, at most, natural evolutions of traditional CBT rather than something fundamentally new. The rise in profile of acceptance-based therapies, Hayes's conceptualization of these as representing a distinctively new epoch in CBT, and the considerable contention surrounding this assertion raise questions about how acceptance-based models of CBT are different from and similar to traditional CBT. Exploration of these questions, in turn, sheds light on important unresolved issues in the field and points toward needed research efforts. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Article
This chapter discusses the treatment for eating disorders. The Diagnostic and Statistical Manual of Mental Disorders recognizes two primary eating disorders: anorexia nervosa (AN) and bulimia nervosa (BN). It also includes binge eating disorder (BED), sub threshold versions of AN and BN, and other disordered eating patterns. The most widely researched treatments for eating disorders are based on cognitive-behavioral procedures and have focused on BN and BED. Acceptance-based methods for treating eating disorders deserve increased attention, and several interventions that incorporate mindfulness training and acceptance-related procedures. Some of these are adaptations of previously developed interventions. For example, dialectical behavior therapy (DBT) has been adapted for BED and BN; mindfulness-based cognitive therapy (MBCT) has been adapted for BED; and acceptance and commitment therapy (ACT) has been applied to AN. In addition, mindfulness-based eating awareness training (MB-EAT) is developed specifically for BED. MB-EAT is developed by integrating elements from MBSR and CBT with guided eating meditations. The program draws on traditional mindfulness meditation techniques, as well as guided meditation, to address specific issues pertaining to shape, weight, and eating-related self regulatory processes such as appetite and both gastric and taste-specific satiety.
Chapter
Classification of Eating Disorders in Childhood and AdolescenceDiagnostic CriteriaClinical FeaturesDistributionDevelopment and Subsequent CourseEtiologyBinge Eating DisorderMedical Complications and their ManagementManagement of Eating DisordersPrevention of Eating DisordersAcknowledgmentsReferences
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The first wave of behavior therapy countered the excesses and scientific weakness of existing nonempirical clinical traditions through empirically studied first-order change efforts linked to behavioral principles targeting directly relevant clinical targets. The second wave was characterized by similar direct change efforts guided by social learning and cognitive principles that included cognitive in addition to behav-ioral and emotive targets. Various factors seem to have set the stage for a third wave, including anomalies in the current literature and philosophical changes. Acceptance and Commitment Therapy (ACT) is one of a number of new interventions from both behavioral and cognitive wings that seem to be moving the field in a different direction. ACT is explicitly contextualistic and is based on a basic experimental analysis of human language and cognition, Relational Frame Theory (RFT). RFT explains why cognitive fusion and experiential avoidance are both ubiquitous and harmful. ACT targets these processes and is producing supportive data both at the process and outcome level. The third-wave treatments are characterized by openness to older clinical traditions, a focus on second order and contextual change, an emphasis of function over form, and the construction of flexible and effective repertoires, among other features. They build on the first-and second-wave treatments, but seem to be carrying the behavior therapy tradition forward into new territory. Over the last several years quite a number of behavior therapies have emerged that do not fit easily into traditional categories within the field.
Book
An ACT Approach Chapter 1. What is Acceptance and Commitment Therapy? Steven C. Hayes, Kirk D. Strosahl, Kara Bunting, Michael Twohig, and Kelly G. Wilson Chapter 2. An ACT Primer: Core Therapy Processes, Intervention Strategies, and Therapist Competencies. Kirk D. Strosahl, Steven C. Hayes, Kelly G. Wilson and Elizabeth V. Gifford Chapter 3. ACT Case Formulation. Steven C. Hayes, Kirk D. Strosahl, Jayson Luoma, Alethea A. Smith, and Kelly G. Wilson ACT with Behavior Problems Chapter 4. ACT with Affective Disorders. Robert D. Zettle Chapter 5. ACT with Anxiety Disorders. Susan M. Orsillo, Lizabeth Roemer, Jennifer Block-Lerner, Chad LeJeune, and James D. Herbert Chapter 6. ACT with Posttraumatic Stress Disorder. Alethea A. Smith and Victoria M. Follette Chapter 7. ACT for Substance Abuse and Dependence. Kelly G. Wilson and Michelle R. Byrd Chapter 8. ACT with the Seriously Mentally Ill. Patricia Bach Chapter 9. ACT with the Multi-Problem Patient. Kirk D. Strosahl ACT with Special Populations, Settings, and Methods Chapter 10. ACT with Children, Adolescents, and their Parents. Amy R. Murrell, Lisa W. Coyne, & Kelly G. Wilson Chapter 11. ACT for Stress. Frank Bond. Chapter 12. ACT in Medical Settings. Patricia Robinson, Jennifer Gregg, JoAnne Dahl, & Tobias Lundgren Chapter 13. ACT with Chronic Pain Patients. Patricia Robinson, Rikard K. Wicksell, Gunnar L. Olsson Chapter 14. ACT in Group Format. Robyn D. Walser and Jacqueline Pistorello
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Recent innovations in behavior modification have, for the most part, detoured around the role of cognitive processes in the production and alleviation of symptomatology. Although self-reports of private experiences are not verifiable by other observers, these introspective data provide a wealth of testable hypotheses Repeated correlations of measures of inferred constructs with observable behaviors have yielded consistent findings in the predicted direction.Systematic study of self-reports suggests that an individual's belief systems, expectancies, and assumptions exert a strong influence on his state of well-being, as well as on his directly observable behavior. Applying a cognitive model, the clinician may usefully construe neurotic behavior in terms of the patient's idiosyncratic concepts of himself and of his animate and inanimate environment. The individual's belief systems may be grossly contradictory; i.e., he may simultaneously attach credence to both realistic and unrealistic conceptualizations of the same event or object. This inconsistency in beliefs may explain, for example, why an individual may react with fear to an innocuous situation even though he may concomitantly acknowledge that this fear is unrealistic.Cognitive therapy, based on cognitive theory, is designed to modify the individual's idiosyncratic, maladaptive ideation. The basic cognitive technique consists of delineating the individual's specific misconceptions, distortions, and maladaptive assumptions, and of testing their validity and reasonableness. By loosening the grip of his perseverative, distorted ideation, the patient is enabled to formulate his experiences more realistically. Clinical experience, as well as some experimental studies, indicate that such cognitive restructuring leads to symptom relief.
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In a multidimensional investigation of issues of control in eating disorders, 52 women with bulimia or anorexia nervosa and 57 comparison women were surveyed regarding their perceptions of control. As predicted, the women with eating disorders reported lower internal control than comparison women but, contrary to prediction, reported lower desire for control. They also reported much higher fear of losing self-control, which emerged as the most significant predictor of eating disorder symptomology for both eating disordered and comparison women. Bulimic and anorexic women did not differ significantly from each other on any of these measures of control. Further research is recommended on the relevance of fear of losing self-control to the treatment and prevention of eating disorders.
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Details the psychometric evaluation of the Quality of Life Inventory (QOLI), a measure of life satisfaction that may complement symptom-oriented measures of psychological functioning in evaluating the outcome of interventions aimed at ameliorating mental disorders, disabling physical illnesses, and community-wide social problems. Test–retest coefficients for the QOLI ranged from .80 to .91, and internal consistency coefficients ranged from .77 to .89 across 3 clinical and 3 nonclinical samples. QOLI item–total correlations were found to be adequate, and the QOLI had significantly positive correlations with 7 related measures of subjective well-being, including a peer rating and clinical interview measure. Significant negative correlations were obtained between the QOLI and measures of general psychopathology and depression. Clinical and nonclinical criterion groups differed significantly in mean QOLI scores. QOLI norms are presented, and the usefulness of the QOLI for assessing treatment outcome and for psychotherapy treatment planning is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)