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Introduction: Eating Disorders and Mindfulness
ByLeah M. DeSole
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This Book of Eating Disorders and Mindfulness brings together some of the most significant research and theory regarding the investigation and application of mindfulness-based interventions in field of eating disorders to date. The idea for this Book originated from my experience working with patients who struggle with eating disorders as well as my personal involvement in the integration of mindfulness and psychology. My interest began over a decade ago when I was introduced to literature in the discipline of psychology proposing how the principles of Eastern philosophy could be integrated and infused within theories of Western psychology. Since then I have explored various ideas and means regarding how to enable people to live in the present, free from the emotional and physical suffering that often is attendant to simply being in the world. In June 2010, I had the opportunity to attend a seven-day professional training in

Mindfulness Based Stress Reduction (MBSR) in mind-body medicine taught by doctors Jon Kabat-Zinn and Saki F. Santorelli. It was an occasion for health care professionals from across the United States and around the world to survey the principle components and practical applications of mindfulness-based approaches to the prevention and treatment of a variety of physical and psychological disorders. The training was both exciting and eye-opening. For over 30 years, professionals at the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School have pioneered the integration of mindfulness into mainstream medicine and psychology through research, treatment and professional education. Since 1979, thousands of professionals have completed training in mindfulness-based medicine practices and tens of thousands of people have participated in MBSR courses. Participants in mindfulness-based approach have experienced marked improvement in both physical and psychological symptoms in addition to significant positive changes in health attitudes and behaviors. While at the conference, I met many mental healthcare professionals who work either with eating disordered patients or patients who are struggling with issues related to disordered eating. These encounters strengthened my resolve to bring this Book to fruition in order to encourage interest in the area and support the work of researchers and professionals who endeavor to bring mindfulness-based approaches to the field of eating disorders. In contrast to Eastern culture, a divide between mind and body has been articulated

in the West since the time of Descartes. Western psychology, however, now recognizes the intricate relationship between mind and body. Nowhere may this be more visible

than it is in the field of eating disorders wherein Descartes’ error, the fallacy of the dualist separation of mind and body or rationality and emotions, is “embodied” in those with whom we work. Indeed, the authors in this diverse issue share not only a common belief in the unity of emotion, reason and the body, but also a sense that mindfulness-based interventions are uniquely designed to address this unity and meet the distinctive needs of those who suffer from eating disorders. Professionals in the field of eating disorders are continually seeking ways to enhance

the provision of treatment and improve outcomes. To this end, there has been a paradigm shift in recent years from traditional therapy models to holistic, multidisciplinary models. Traditional therapy models, such as cognitive behavior therapy (CBT) and Interpersonal Psychotherapy (IPT), emphasize thought-driven analysis and verbal interpretation in their approach to treatment. In contrast, multidisciplinary models such as Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Cognitive Therapy (MBCT) call attention to body based processes (i.e., the experience of emotions and physical sensations) within the context of the therapeutic relationship. These “third wave” therapies draw upon scientifically based research in developmental psychobiology and affective neuroscience to deepen our understanding of how the brain and the body come together in the development, manifestation and treatment of eating disorders. Empirically validated mindfulness-based interventions have been applied in clinical

settings for the relief of chronic pain as well as the promotion of effective emotional regulation for several decades. In contrast, mindfulness as it is applied to the prevention and treatment of eating disorders is in its nascent stage. Thus, the ten chapters included in this Book are investigatory in nature. They cover a range of eating disorders (Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder), treatment modalities (individual and group) and treatment settings (inpatient and outpatient). Although it may be operationalized in different ways, unifying these chapters is a common definition of mindfulness: meeting the present moment with full, nonjudgmental attention to one’s thoughts, feelings, behavior and body. To understand what mindfulness is, take a moment for this exercise. Stop. As you

look at this page, notice the thoughts that arise in your mind. Perhaps you are thinking “How can they make an entire Book out of this subject?” Likewise, observe your feelings. Is annoyance brewing? Or are you feeling excited? Now try to discern what is happening in your body. Are your brows furrowed and is your jaw tightening or are the muscles of your face relaxed? What about the sensations in the rest of your body, e.g., your shoulders or stomach, can you describe them? Most importantly, can you go further and consider the quality of your awareness regarding your thoughts, feelings and physical sensations taken as a whole. What is the nature of it? For example, are you saying to yourself, “Oh, I ought to give this a chance. Why am I so skeptical?” A mindfulness-based approach would encourage you not to judge your awareness. Rather, you would be encouraged to notice it without evaluation; to meet your experience as a witness rather than a critic, in the same way that a researcher would observe an experiment. How to make mindfulness meaningful and integrate it into the theory, research and

treatment of eating disorders is the challenge of this Book. The first five chapters in this collection are empirical in nature. The majority take as

their focus mindfulness applications to group therapy treatments. We begin with a pilot study by Natasha Hepworth, “A Mindful Eating Group as an Adjunct to Individual

Treatment for Eating Disorders,” in which participants with a range of eating disorder diagnoses participated in a short-term manualized, mindfulness-based treatment group as a complement to individual therapy. The next chapter by Kathryn Proulx, “Experiences Of Women with Bulimia Nervosa in a Mindfulness-Based Eating Disorder Treatment Group,” examines the effectiveness of a mindfulness intervention not as an adjunct to treatment, but as a primary treatment modality. Subsequently, Hannah Woolhouse, Ann Knowles and Naomi Crafti investigate the effectiveness of a combined mindfulness and CBT group therapy program in “Adding Mindfulness to CBT Programs for Binge Eating: A Mixed-Methods Evaluation.” This investigation continues with an chapter by Christine Courbasson, Yasunori Nishikawa and Leah Shapira. Their contribution, “Mindfulness-Action Based Cognitive Behavioural Therapy for Concurrent Binge Eating Disorders and Substance Use Disorders,” also highlights the importance of acknowledging how eating disorders often do not occur alone, but rather present as comorbid concerns in treatment. This group of chapters concludes with “The Application Of Mindfulness To Eating Disorders Treatment: A Systematic Review” by Rocío Guardiola Wanden-Berghe, Javier Sanz-Valero, and Carmina Wanden-Berghe. Using a systematic review technique, the authors provide a preliminary review of research investigating the application of mindfulness to the treatment of eating disorders. They not only document the increase in interest in mindfulness in the field of eating disorders, but also find preliminary evidence of its efficacy in clinical practice. The next three chapters are primarily qualitative, although some preliminary

research data is presented. In the first chapter in this group, “Mindfulness-Based Eating Awareness Training for treating Binge Eating Disorder: The Conceptual Foundation,” Jean Kristeller and Ruth Wolever outline the conceptual foundation and key components of a program they developed for the treatment of Binge Eating Disorder. In addition, they present current research and preliminary data regarding the efficacy of their program. Notably, the authors have developed a program that uses mindfulness as its foundation rather than an added technique. The second chapter in this section, “Psychological Inflexibility and Symptom Expression in Anorexia Nervosa,” outlines an elaborate theoretical model of Anorexia Nervosa. Authors Rhonda Merwin, C. Alix Timko, Ashley Moskovich, Krista Konrad Ingle, Cynthia Bulik, and Nancy Zucker explore the ways in which mindfulness-based approaches may be utilized to address the particular concerns of individuals with anorexia nervosa, such as emotional regulation and distress intolerance. This section concludes with an chapter by Laura Douglass, “Thinking Through the Body: The Conceptualization of Yoga as Therapy for Individuals with Eating Disorders.” In it, she insightfully grounds the mindfulness techniques of yoga in the disciplines of neuroscience and sociology as well as the philosophic underpinnings of yoga itself. She thoughtfully advocates for body based interventions and provides an explicit understanding of the inclusion of yoga in the treatment of individuals with eating disorders. Also included are two feature chapters that are clinical in character. Two clinicians

each write of their own experiences applying mindfulness to the treatment of eating disorders. First, Susan Albers describes the application of the principles of mindful eating to the short-term treatment of an individual with anorexia nervosa in a case study, “Using Mindful Eating to Treat Food Restriction.” Finally, Robin Boudette writes in touching detail how her practice and study of mindfulness has changed the

way that she works as a psychologist treating eating disorders in “Integrating Mindfulness into the Therapy Hour.” In the concluding chapter of this issue, Robin Boudette explicitly addresses the

importance of therapists’ developing their own capacity to be mindful before they take the step of applying mindfulness-based approaches themselves. Indeed, a general principle echoed by many of the authors in this issue is that doing this work is more complicated than it may appear on the surface. Moment to moment awareness of one’s thoughts, feelings and sensations-without judgment-is no easy feat. Working consistently in this fashion with patients must come out of one’s own extensive personal experience. Many agree that ultimately it is the strength of one’s personal commitment to becoming mindful in everyday life that is the most important ingredient to applying mindfulness-based approaches in one’s professional life. Thus, it is imperative that we prepare our minds mindfully to meet both the world and our patients if we are to respond authentically and skillfully to our patients’ needs.