Journal of Contextual Behavioral Science 6 (2017) 1–7

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Journal of Contextual Behavioral Science

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Empirical Research

A pilot study of an acceptance-based behavioral treatment for binge eating MARK

disorder
⁎
Adrienne S. Juarascio , Stephanie M. Manasse, Hallie M. Espel, Leah M. Schumacher,
Stephanie Kerrigan, Evan M. Forman
Drexel University, Department of Psychology, Stratton Hall, 3141 Chestnut Street, Philadelphia, PA 19104, USA

A R T I C L E I N F O A BS T RAC T

Keywords: While existing treatments produce remission in a relatively large percentage of individuals with binge eating
Binge eating disorder disorder (BED), room for improvement remains. Interventions designed to increase emotion regulation skills
Acceptance-based treatment and clarify one's chosen values may be well-suited to address factors known to maintain BED. The current study
Group therapy examined the preliminary efficacy of a group-based treatment, Acceptance-based Behavioral Therapy (ABBT), in
a small open trial (n=19), as well as the relationship between changes in hypothesized mechanisms of action and
outcomes. ABBT includes the behavioral components of cognitive behavioral treatment for BED and emotion-
focused strategies from acceptance and commitment therapy and dialectical behavioral therapy. Results from
generalized linear multilevel modeling revealed significant fixed linear effects of time on depression, quality of
life, global eating pathology, and binge frequency (all ps < .05). Global eating disorder symptoms appeared to
improve rapidly from pre- to mid-treatment, and continued to improve toward post-treatment and follow-up,
but at a slower rate. Binge frequency decreased rapidly from pre- to mid-treatment, followed by a slight increase
at post-treatment and a reduction again by follow-up. Improvements in experiential acceptance were strongly
and consistently related to decreases in overall eating pathology across several measures (rs=.35–.54).
Additionally, greater access to emotion regulation strategies was strongly related to decreases in overall eating
pathology (r=.67). Preliminary results support the efficacy of this novel treatment approach and indicate that
additional research on ABBT for BED is warranted.

1. Introduction treatment (Hilbert et al., 2012).

Traditional cognitive behavioral models of binge eating emphasize
1.1. Binge eating disorder reducing dietary restriction as the core mechanism of action in
treatment (Fairburn, Wilson, & Schleimer, 1993). However, a growing
Binge eating disorder (BED) is the most common eating disorder body of literature has highlighted the role of emotion regulation
(Hudson, Hiripi, Pope, & Kessler, 2007), and is associated with difficulties and negative affect in binge eating (Agras & Telch, 1998;
adverse health effects and impaired quality of life (Grilo, White, & Deaver, Miltenberger, Smyth, Meidinger, & Crosby, 2003; Munsch,
Masheb, 2009). Although several treatments, such as interpersonal Meyer, Quartier, & Wilhelm, 2012). Research suggests that negative
therapy and dialectical behavior therapy (DBT), have shown efficacy in affect may be particularly influential for a subgroup of patients (Grilo,
treating BED (e.g., Safer & Jo, 2010; Telch, Agras, & Linehan, 2001; Masheb, & Wilson, 2001; Stice et al., 2001), and that emotionally
Wilfley et al., 2002), cognitive behavioral therapy (CBT) currently has driven eating may predict treatment resistance (Ricca et al., 2010).
the strongest research support (Vocks et al., 2010). A recent meta- Although newer “enhanced” cognitive behavioral treatments (e.g., CBT-
analysis revealed that cognitive behavioral interventions for BED result E, Fairburn, 2008; Fairburn, Cooper, & Shafran, 2003) place greater
in medium-to-large improvements in binge eating (Vocks et al., 2010). emphasis on the role of negative affect in binge eating, mood intoler-
However, room for improvement remains. A significant proportion of ance is not addressed until later in treatment (i.e., after several
patients continue to binge eat following treatment and some patients sessions; Fairburn, 2008). Though the amount of time spent addressing
may lose treatment gains over time; for example, in one large trial of emotion regulation is tailored to patient needs, the skills provided for
CBT, only 52% individuals experienced full recovery four years after addressing mood intolerance also are limited (Ricca et al., 2010).

⁎
Corresponding author.
E-mail address: asj32@[Link] (A.S. Juarascio).

[Link]
Received 7 October 2016; Received in revised form 27 December 2016; Accepted 28 December 2016
2212-1447/ © 2017 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
A.S. Juarascio et al. Journal of Contextual Behavioral Science 6 (2017) 1–7

Additionally, while the behavioral components of CBT for BED (e.g., individuals to successfully alter eating behaviors. Additionally, a recent
self-monitoring of eating behavior, regularization of eating; Fairburn, systematic review indicated that DBT may significantly reduce eating
2008; Mitchell, Devlin, de Zwaan, Crow, & Peterson, 2008) appear pathology, improve mood and affect, and enhance retention (Bankoff,
critical for reducing binge eating (Wilson, Fairburn, Agras, Walsh, & Karpel, Forbes, & Pantalone, 2012). Several case series studies (e.g.,
Kraemer, 2002; Zendegui, West, & Zandberg, 2014), many patients Berman, Boutelle, & Crow, 2009; Hill, Masuda, Melcher, Morgan, &
struggle to implement the behavioral recommendations, in part Twohig, 2015; Wildes & Marcus, 2011), small pilot trials (Klein,
because these behaviors can initially bring on emotional discomfort Skinner, & Hawley, 2012, 2013), and randomized controlled trials
and require significant time investment on the part of the patient (Juarascio et al., 2013; Safer & Jo, 2010) have also all supported the
(Wilson & Vitousek, 1999). CBT treatments provide patients with very efficacy of both ACT and DBT for the treatment of BED and other
few skills that are meant to enhance willingness to implement challen- eating disorders. Additional emotion-focused treatments, such as
ging behavioral recommendations, especially early in treatment. Integrative Cognitive Affective Therapy (ICAT), have shown encoura-
Increasing skills for coping with negative affect and enhancing patients’ ging results in a sample of patients with bulimia nervosa (Wonderlich
willingness to engage in the behavioral elements of CBT for BED, et al., 2014), and are currently under evaluation for BED.
despite discomfort and time investment, appear to be two key areas for As summarized previously, preliminary results suggest that third-
improving current treatments. wave treatments show promise for the treatment of BED. However,
“Third wave” acceptance-based behavioral treatments may be limited research has examined whether third-wave principles and
particularly well-suited to target patients’ difficulty coping with nega- strategies (drawn from ACT, DBT, and behavioral activation) can
tive affect and increasing willingness to engage in challenging beha- feasibly be integrated into a treatment that also delivers the behavioral
vioral components of treatment. In particular, concepts and skills strategies essential to CBT, whether such a treatment approach is
taught in Acceptance and Commitment Therapy (ACT; Hayes, efficacious, and whether such a treatment improves participants’ ability
Strosahl, & Wilson, 2011), brief behavioral activation treatment for to regulate emotions and reduce binge eating. Our team recently
depression (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011), and developed a treatment that integrates third wave principles with the
DBT (Linehan, 1993) may hold promise for improving treatment behavioral strategies of CBT and have termed this treatment accep-
outcomes when used in conjunction with behavioral components of tance-based behavioral therapy (ABBT). The ABBT that we developed
CBT for BED. For example, ACT's focus on values clarification (i.e., targets affective triggers for binge eating while also retaining the
identifying the life domains and principles that are most important to behavioral components considered necessary to normalized daily
individuals), psychological acceptance (i.e., experiencing one's internal eating patterns. Although existing treatments such as CBT-E do include
experiences without judgment), and committed action (i.e., developing a small number of ABBT techniques later in treatment, the utility of
patterns of behavior that are consistent with one's chosen values) may integrating ABBT techniques throughout a behavioral treatment has
provide patients with the motivation and skills needed to engage in yet to be studied. Importantly, integrating affect regulation skills early
distressing behavioral components of treatment (Hayes et al., 2011; in treatment also necessitates reducing the session time spent on
Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Manlick, Cochran, & fundamental skills of normalizing eating patterns and optimizing self-
Koon, 2013). Similarly, behavioral activation treatment emphasizes monitoring; this could potentially reduce treatment efficacy. On the
identification of valued life domains and purposeful engagement in other hand, as stated above, it is also possible that early integration of
important and/or enjoyable activities (Lejuez et al., 2011). Engagement affect regulation skills may promote more rapid clinical improvement
in values-consistent activities that are important and/or enjoyable may by providing greater time to practice skills that target affect triggers of
improve patients’ overall mood, thereby reducing the frequency and binge eating. Thus, evaluation of the preliminary efficacy of this new
intensity of negative affect and, potentially, the frequency of affect- approach through an open trial was warranted. Furthermore, because
induced binge episodes. Finally, the distress tolerance and emotion these added treatment components are designed to reduce depressive
regulation skills taught in DBT (Linehan, 1993) may provide patients symptoms and improve overall quality of life through improved
with numerous concrete, in-the-moment strategies for coping with emotional coping, it was also important to evaluate the impact of the
negative affect without binge eating. These approaches may be treatment on these outcomes. For an in-depth discussion of the
particularly effective when used with the behavioral strategies empha- rationale for and process of incorporating acceptance-based treatment
sized in CBT to reduce dietary restriction. components with the behavioral elements of CBT for BED, as well as
feasibility and acceptability data related to this treatment approach, see
1.2. Evidence for efficacy of third-wave treatments for BED and Juarascio, Manasse, Schumacher, Espel, and Forman (2016).
related disorders Finally, it was also important to determine whether an intervention
utilizing third-wave treatment components for BED actually functions
There is early evidence for the efficacy of third-wave interventions through the hypothesized mechanisms of action. Despite recent calls
for binge eating. Recent meta-analyses of several third-wave ap- for an increased emphasis on identifying mechanisms of action and
proaches (e.g., mindfulness-based eating awareness training assessing whether treatments are impacting their identified clinical
(Kristeller & Wolever, 2010), ACT, DBT) have revealed a medium- targets to better inform the development of new treatments (Insel,
to-large effect of these interventions on binge eating (Godfrey, Gallo, & 2014; NIMH, 2014), analyses of mechanisms of action in eating
Afari, 2015; Katterman, Kleinman, Hood, Nackers, & Corsica, 2014). disorder treatment outcome trials are rare. Third-wave treatments for
In particular, mindfulness-based interventions appear to increase self- BED have been hypothesized to reduce reliance on binge eating
efficacy and sense of control around eating, promote non-judgmental behavior as a means of coping with negative affect by providing
self-acceptance, and reduce frequency of binge episodes (Baer, Fischer, patients with new skills (e.g., acceptance, willingness, and other
& Huss, 2005; Godfrey et al., 2015; Katterman et al., 2014; Kristeller, emotion coping strategies) to apply when distressing emotions arise
Wolever, & Sheets, 2014). One analog study found that acceptance as (Kristeller et al., 2014; Safer & Jo, 2010; Wildes & Marcus, 2011).
an emotion regulation strategy did not significantly outperform rumi- Thus, these treatments would be expected to produce improvements in
nation on body dissatisfaction in women with binge eating, but did acceptance of and willingness to experience distress related to eating
improve mood (Svaldi & Naumann, 2014). Research on third wave behavior specifically and more broadly, as well as in emotional
treatments for weight control has also produced favorable results regulation abilities. By addressing emotion regulation skills more
(Forman, Butryn, Hoffman, & Herbert, 2009; Mantzios & Wilson, globally, these treatments are also thought to reduce other maladaptive
2014, 2015; Niemeier, Leahey, Reed, Brown, & Wing, 2012), indicat- emotional response patterns perhaps not directly tied to binge eating,
ing that the unique skills discussed in these treatments may help such as negative urgency (i.e., the tendency to act rashly when

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A.S. Juarascio et al. Journal of Contextual Behavioral Science 6 (2017) 1–7

experiencing negative affect; Whiteside, Lynam, Miller, & Reynolds, among eating disorder samples (Cooper, Cooper, & Fairburn, 1989).
2005) Unfortunately, however, a recent systematic review completed Global scores represent average symptom severity across the four
by our team found that third-wave treatment trials for BED and subscales/dimensions.
bulimia nervosa rarely assess or report on mechanisms of action
(Barney et al. under review), so it is yet unclear whether these 2.2.2. Mini International Neuropsychiatric Interview (MINI)
treatments function as theory suggests they would. It is possible that The MINI is a brief structured interview used to assess for
the benefit of new third-wave treatments is driven by the same comorbid psychopathology (Sheehan & Lecrubier, 2010). The MINI
behavioral mechanisms (i.e., self-monitoring and normalization of has demonstrated high clinical validity and reliability, while maintain-
eating patterns) as those of standard CBT treatments, rather than ing efficiency and reducing participant burden (Lecrubier et al., 1997;
improvements in processes that are uniquely addressed in third-wave Sheehan & Lecrubier, 2010).
treatments. Therefore, in addition to evaluating the efficacy of ABBT
for BED on binge frequency and global eating disorder psychopathol- 2.2.3. Quality of Life Inventory (QOLI)
ogy, it was also important to evaluate the impact of ABBT on The QOLI assesses an individual's life satisfaction in each of sixteen
hypothesized mechanisms of action, specifically, emotion dysregula- areas identified as important to him/her (Frisch, 1994). It has
tion, acceptance of experiential distress (related to eating and more demonstrated adequate validity, reliability, and consistency (Frisch,
broadly), and negative urgency. Cornell, Villanueva, & Retzlaff, 1992).

1.3. Aims of the current study 2.2.4. Beck Depression Inventory-II (BDI-II)
The BDI-II assesses depressive symptoms. The measure has high
The current study aimed to assess the preliminary efficacy of ABBT internal consistency and validity among psychiatric outpatients (Beck,
for BED in reducing binge frequency and improving eating pathology, Steer, & Brown, 1996).
depressive symptoms, and overall quality of life. Additionally, we
sought to understand whether changes in hypothesized mechanisms 2.2.5. Difficulties in Emotion Regulation Scale (DERS)
of ABBT are related to outcome. We hypothesized that patients who The DERS assesses difficulty with identifying and regulating
received ABBT would experience clinically significant reductions in aversive emotional experience across six domains, i.e.,
binge episodes, eating pathology, psychiatric comorbidity and improve- Nonacceptance of Emotional Responses, Difficulties Engaging in
ments in quality of life. We also hypothesized that changes in the Goal-Directed Behavior, Impulse Control Difficulties, Lack of
hypothesized mechanisms of action would be associated with symptom Emotional Awareness, Limited Access to Emotion Regulation
improvements. Strategies, and Lack of Emotional Clarity. The DERS has strong
internal consistency and test-retest reliability (Gratz & Roemer,
2. Methods 2004). Higher scores on all subscales represent greater difficulty with
identifying and regulating aversive emotions.
2.1. Participants
2.2.6. Acceptance and Action Questionnaires—general and food-
Adult females (n=19) were recruited via distribution of flyers, specific
targeted emails sent out to our university, and posting in online Acceptance of general internal experiences was measured using the
forums. Participants were eligible if they were between the ages of 18 Acceptance and Action Questionnaire-II (AAQ-II), which is a 7-item,
and 65 and endorsed at least 12 objective binge episodes in the past 3 single factor self-report measure that is used transdiagnostically in
months, consistent with DSM-5 criteria. Exclusion criteria included acceptance-based treatments (Bond et al., 2011). The Food Craving
severe psychiatric comorbidity (e.g., psychosis) and previous cognitive Acceptance and Action Questionnaire (FAAQ; Juarascio, Forman,
behavioral or acceptance-based treatment for BED. Timko, Butryn, & Goodwin, 2011) was used to assess acceptance of
A total of 198 potential participants were screened over the phone internal experiences specifically related to eating behavior, and has two
to assess for preliminary eligibility. Thirty-seven individuals were subscales: acceptance and willingness. Both the AAQ-II and the FAAQ
invited to come to the lab for a full diagnostic interview, of whom 13 have strong psychometric properties. Higher scores on both measures
were excluded because they: were currently engaging in compensatory reflect greater acceptance.
behaviors (n=3); failed to meet binge frequency or loss-of-control
criteria for BED (n=6); exhibited cognitive impairment that interfered 2.2.7. UPPS Impulsive Behavior Scale—negative urgency subscale
with ability to benefit from treatment (n=1); had recent bariatric The 12-item Negative Urgency subscale of the UPPS Impulsive
surgery (1); or failed to come in for an assessment (n=2). Excluded Behavior Scale (Whiteside et al., 2005) was used to measure the
participants were provided appropriate referrals. tendency to act rashly under negative affective states. The full scale has
Though males were considered eligible for the study, the final demonstrated sound psychometric properties (Whiteside et al., 2005).
sample consisted only of female participants, whose ages ranged from Higher scores indicate greater negative urgency.
20 to 63 years (M=38.26; SD=14.41). A majority of participants were
overweight or obese, and average body mass index was 32.80 kg/m2 2.3. Treatment
(SD=8.98). Participants were predominantly Caucasian (n=13); the
remainder of the sample identified as Hispanic (n=2), Asian-American The group-based ABBT treatment was delivered over 10 weekly
(n=2), and African-American (n=2). All participants who enrolled in sessions to three groups (five to seven participants each). The first two
treatment are included in the analyses. sessions were 120 min each; remaining sessions were 90 min. Each
group was co-led by two therapists, who were licensed clinical
2.2. Measures psychologists or advanced doctoral students in clinical psychology
supervised by a Ph.D.-level psychologist.
2.2.1. Eating Disorders Examination Interview 16.0 (EDE) Each session followed a general format, which included individual
The EDE (Cooper & Fairburn, 1987) is a semi-structured diag- participant check-ins, review of skills from the previous session,
nostic interview for eating disorders. Inter-rater reliability between introduction of new skills and concepts, and assignment of homework.
trained interviewers and test-retest reliability is high (Rizvi, Peterson, Core behavioral elements of traditional CBT for binge eating were
Crow, & Agras, 2000) and the measure has good internal consistency included as essential foundational principles of the treatment, includ-

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Table 1
Change in eating disorder symptoms, depression, and quality of life during treatment.

Outcome Measure Pre-Treatment Mid-Treatment Post-Treatment 3-Month Follow-Up Fixed Effects

M (SD) M (SD) M (SD) M (SD) b (SEb)
Model Term (n =19) (n =18) (n =17) (n =15)

EDE Global 2.64 (.84) 1.86 (.71) 1.60 (.63) 1.58 (.98)
Time −.16 (.03)***
Time2 .01 (.00)***
Binge 16.82 (8.62) 1.35 (2.00) 3.29 (7.90) 1.33 (2.47)

Frequencya
Time −.77 (.12)***
Time2 .08 (.02)***
Time3 −.002 ( < .01)***
BDI-II 20.37 13.11 11.25 10.33
(11.60) (12.21) (13.72) (10.26)

Time −1.26 (.35)***

Time2 .04 (.01)**
QOLI −.23 (2.00) – 1.18 (1.89) 1.14 (1.85)
Time .06 (.03)*

Notes. b-values represent average change in each outcome variable per week. BDI-II = Beck Depression Inventory-II. QOLI = Quality of Life Inventory.
a
Binge frequency regression weights were calculated after log-transformation; Ms and SDs represent untransformed values from raw participant data.
*
p < .05.
**
p < .01.
***
p < .001.

ing weekly self-weighing, normalization of eating patterns, and daily Linear, quadratic, and cubic fixed effects of time were tested for each of
self-monitoring of food intake and emotions. However, the treatment the outcome variables (binge frequency and EDE Global, BDI-II, and
expanded upon traditional CBT by incorporating several acceptance- QOLI scores). Logarithmic transformation was applied to binge
based psychological strategies in lieu of traditional cognitive strategies frequency data to normalize the distribution. Likelihood ratio tests
(which were not included in ABBT). The inclusion of these strategies (LRT) were conducted to determine whether random linear and
was intended to help participants overcome common barriers (e.g., low quadratic effects contributed significantly to model fit, using the
motivation, distress related to treatment components) to engaging in criterion p≤.05 for the χ2 statistic. Descriptive and correlational
recommended behaviors, and to improve tolerance of distress and analyses were performed in SPSS version 23. Because we anticipated
negative affect. Participants were encouraged to clarify their personal large improvements in both process and outcome measures by the mid-
values, and to draw a connection between the behavioral strategies treatment assessment point, formal mediation analyses were not
introduced in treatment and these values. Specific psychological possible. We thus elected to evaluate the correlations between pre- to
strategies that were added to help facilitate this valued action included post-treatment change in both process measures and EDE Global
both acceptance- and change-strategies, such as cognitive defusion, score. Because our small sample did not provide adequate power for
urge surfing, distress tolerance skills, willingness, and emotional formal significance testing, we noted whether correlations reached a
awareness. Participants were also provided with emotion regulation medium effect size (i.e., r≤.3). Correlations between pre- to post-
strategies drawn from DBT, and were instructed to engage in values- treatment change in process measures and pre- to post-treatment
based behavioral activation in order to improve overall mood. For more change in binge frequency were not examined, as it was determined
information regarding the development and implementation of ABBT that these evaluations would largely reflect differences in baseline
for BED, see Juarascio et al. (2016). values since the vast majority of participants experienced no or rare
binge eating at post-treatment assessment.
2.4. Assessment procedures
3. Results
Participants underwent a 20-min phone screen to determine initial
study eligibility. Eligible participants provided informed consent and 3.1. Symptom improvement over time
completed an in-person interview, which included administration of
the EDE 16.0 and the MINI 6.0 by a trained diagnostician and the self- A majority of participants experienced early remission of binge
report measures listed above. eating symptoms, which was maintained through the follow-up period.
Mid-treatment (5 weeks) and post-treatment (10 weeks) assess- At mid-treatment, ten of eighteen participants (56%) were abstinent
ments included the EDE (assessing binge eating for only one month from objective binge eating in the four weeks prior to assessment. This
prior, as three months would overlap with the pre-treatment time rate remained relatively consistent at subsequent assessments, with
period) and self-report measures. Follow-up (3 months after treat- 59% abstinent at end-of-treatment (10/17) and 60% abstinent at 3-
ment) assessment included the EDE, self-report measures, and quali- month follow-up (9/15).
tative interview. Results from LRT indicated that inclusion of random slopes did not
significantly improve model fit for any of the outcome variables (ps≥.37
2.5. Data analyses for Wald's χ2 statistics). All models therefore include random intercepts
but only fixed effects of time. Results from final optimized models are
Analyses evaluating symptom improvement over time were per- presented in Table 1. Results from generalized linear multilevel
formed in R version 3.1.2 using the “lme4″ (Bates, Maechler, Bolker, modeling revealed significant fixed linear effects of time on BDI-II,
& Walker, 2014) package for generalized linear mixed/multilevel QOLI, and EDE Global scores, and binge frequency. Quadratic effects
modeling. For all models, observations of the outcome variables across of time on BDI-II and EDE Global scores and binge frequency were also
time (Level 1) were nested within individual participants (Level 2). detected; in particular, global eating disorder symptoms appeared to

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Table 2
Overall change in process measures and association with treatment outcome.

Pre-Treatment Mid-Treatment Post-Treatment F ηp2 Correlation with EDE Global changea

M (SD) M (SD) M (SD)

(n =19) (n =18) (n =17)

EDE – Restraint 1.98 (1.23) 1.22 (1.51) 1.24 (.86) 5.33* .25 .22
EDE – Eating Concern 1.31 (.88) 1.60 (.72) .52 (.54) 6.71* .30 .81**
EDE – Shape Concern 3.76 (1.00) 2.97 (.97) 2.42 (1.08) 18.19** .53 .69**
EDE – Weight Concern 3.54 (1.27) 2.52 (1.16) 2.24 (.99) 12.24** .43 .89**
BDI – II 20.37 (11.60) 13.11 (12.21) 11.25 (13.72) 5.18* .26 .39
DERS – Nonacceptance 18.06 (4.00) 15.63 (3.10) 16.63 (4.75) 3.52* .19 .54*
DERS - Goals 12.06 (2.41) 12.19 (2.76) 12.25 (3.66) .03 < .01 .16
DERS – Impulse 17.25 (3.55) 15.44 (2.71) 16.44 (4.37) 1.73 .10 .19
DERS – Awareness 18.06 (4.48) 18.75 (3.30) 17.75 (5.26) .38 .03 −.39
DERS – Strategies 20.63 (4.57) 18.25 (2.67) 19.56 (5.29) 2.09 .12 .67**
DERS – Clarity 11.88 (2.58) 12.81 (2.86) 13.06 (3.19) 1.35 .08 −.37
DERS – Total 100.21 (10.40) 95.39 (9.46) 95.69 (13.85) 1.46 .09 .34
FAAQ – Willingness 15.22 (6.20) 21.89 (6.09) 23.22 (6.46) 7.52** .48 −.26
FAAQ – Acceptance 14.00 (6.16) 15.89 (5.16) 15.89 (5.13) 2.09 .21 −.35
AAQ-II 26.75 (9.89) 29.19 (6.46) 32.19 (9.48) 3.40* .19 −.41
UPPS – Urgency 2.52 (.64) 2.49 (.47) 2.09 (.57) 3.87* .22 −.29

a
Pre-post-treatment change correlated with pre-post-treatment change in EDE Global score.
*
p < .05.
**
p < .01.

improve rapidly from pre- to mid-treatment, and continued to improve participants initially struggled to maintain the momentum of their
toward post-treatment and follow-up, but at a slower rate (see Table 1 early symptom improvements, but that they eventually stabilized
for descriptives). Significant cubic time effects were present for only (perhaps with continued practice of skills taught in treatment after
binge frequency, indicating that participants experienced a temporary the program ended). We can only conjecture as to the cause of this
increase in binge frequency after initial improvement had already been temporary difficulty, but possibilities include situational life stressors
made. Examination of mean binge frequency data at each assessment or motivational factors.
point is consistent with this combined cubic/quadratic model, in that Interestingly, temporary post-treatment increases were not ob-
participants experienced the greatest average reduction in binge served for other outcome variables. Overall eating pathology showed
frequency during the first five weeks of treatment, but also experienced steep improvement from pre- to mid-treatment and then a continuing,
a relative increase between five and ten weeks that resolved by the end though less rapid, improvement at both post-treatment and follow-up.
of the follow-up period (Table 1). Mood symptoms demonstrated a similar pattern of results, with the
average participant moving from the moderate to minimal range for
3.2. Process measures and associations with symptom change depressive symptoms on the BDI-II by post-treatment. This result was
sustained, and even slightly improved, by follow-up. Lastly, quality of
Medium-to-large improvements were observed across most process life showed substantial improvements by post-treatment and this
measures, with the exception of the Goals, Awareness, and Clarity improvement was sustained at 3-month follow-up. Overall, the results
subscales of the DERS (see Table 2). Associations between pre- and from our pilot trial thus demonstrate clear and sustained improvement
post-treatment changes in process measures and pre- to post-treat- in both eating disorder-specific symptoms and other relevant out-
ment changes in EDE Global score are presented in Table 2. Decreases comes.
in EDE Global scores were related to improvements in the Although we were under-powered to utilize standard tests of
Nonacceptance and Strategies subscales of the DERS, the Acceptance mediation, simple comparisons of change scores lend initial support
subscale of the FAAQ, and to AAQ-II scores. Decreases in EDE Global to our theoretical model. Medium-to-large improvements were ob-
scores were also related to worsening in the Clarity and Awareness served in experiential acceptance (both generally and of food-related
subscales of the DERS. All of these relationships were at least medium internal experiences), negative urgency, and in several domains of
in effect size. emotion regulation. Improvements in experiential acceptance were
strongly related to decreases in overall eating pathology across several
4. Discussion measures. Additionally, greater perceived access to emotion regulation
strategies was strongly related to decreases in overall eating pathology.
These findings support the preliminary efficacy of ABBT for BED. If replicated, these results provide support for the notion that ABBT
Although the current pilot study did not compare ABBT to an existing functions through its hypothesized mechanisms. Of note, increases in
treatment approach (CBT or another third-wave approach), the mag- awareness and clarity of emotional experiences were related to lesser
nitude of the improvements observed were similar to those of other improvements in overall eating pathology. While surprising in some
treatments for BED (e.g., Godfrey et al., 2015) and demonstrated the respects, this finding is consistent with previous reports (Cardaciotto,
promise of this novel treatment approach. Participants experienced Herbert, Forman, Moitra, & Farrow, 2008), and has been interpreted
rapid decreases in binge frequency early in treatment, and although as indicating that awareness in and of itself may actually increase focus
some participants experienced a slight uptick between mid-treatment on negative internal experiences, particularly if the individual is not
and post-treatment, 3-month follow-up results again showed a reduc- accepting of those experiences.
tion to very low rates of binge eating. Importantly, the change from The current study featured several notable strengths. First, this
mid- to post-treatment appeared to be driven primarily by a marked study was the first to develop and evaluate a values-based emotion-
increase in binge frequency experienced by two participants at post- focused treatment for BED that directly attempted to integrate
treatment, which resolved by follow-up. Thus, it appears that these acceptance-based skills into existing cognitive behavioral treatments.

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This work was funded by two awards from the National Institutes of Juarascio, A., Shaw, J., Forman, E., Timko, C. A., Herbert, J., Butryn, M., & Lowe, M.
Mental Health (K23MH105680 and F31MH108279) to Dr. Juarascio (2013). Acceptance and commitment therapy as a novel treatment for eating
and Ms. Manasse, respectively, and a research grant from the disorders: An initial test of efficacy and mediation. Behavior Modification
(0145445513478633).
Innovation Lab (EMF 041013).

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