Clinical Handbook of Mindfulness (75 page)

2002),
suggesting that distorted appearance-related cognitions lead to behavioral restraint (e.g., dieting), which then leads to eating pathology.

Such appearance-related thoughts are one form of perfectionistic thinking

common in ED (see
Bardone-Cone et al., 2007
for a review). In perfectionism, individuals hold extraordinarily high standards for performance, appear-

ance and/or achievement and tend to have poor tolerance for outcomes that

are not consistent with meeting personal standards (see
Bardone-Cone et al.,

2007
for a review). Ironically, since measures of success tend to be inordinately unrealistic, perfectionistic individuals with ED are chronically dis-

satisfied due to holding unattainable eating, weight, and shape-related goals

(Steele, Corsini, & Wade, 2007)
and are known to frequently experience feelings of shame
(Swan & Andrews, 2003; Lawson, Waller & Lockwood,

2007).Residual
perfectionistic beliefs observed in recovered ED patients are seen as indicators of risk for relapse
(Lilenfeld et al., 2000).

Clinical severity of ED is also related to severely distorted, rigid and even

magical cognitions about the relationship of food-related thoughts to eating,

body weight and shape
(Shafran et al., 1999;
Shafran & Robinson, 2004;
Spangler,
2002).
Termed thought-shape fusion (TSF), this cognitive characteristic reflects beliefs that merely thinking about foods considered “forbidden”: (1)

increases the likelihood that the individual has gained weight, (2) is morally

equivalent to actually consuming such problematic foods, and (3) leads to

the individual experiencing him or herself as feeling heavier
(Shafran et al.,

1999).
Thus, thoughts about difficult foods are fused with the belief that such thoughts can directly influence weight or shape as well as impact one’s

self-evaluation as immoral and somatically fatter. From a self-regulatory stand-

point, TSF has been associated with the urge to engage in compensatory

behaviors including body checking, exercise and even purging (see Shafran

& Robinson.,
2004
for a discussion).

Attemps to Regulate Cognition through Behavior

(Mental Control)

I eat merely to put food out of my mind
.

∼N.F. Simpson, Playwright

As some models posit that cognition is used to manage behavior, oth-

ers suggest that behavior is used to manage cognition. One well-accepted

theory posits that ED behaviors are maintained through avoidance of aver-

sive self-awareness (e.g., Heatherton et al.,
1991);
mental control theory

(Wegner, 1994)
further informs this approach. Preoccupation with body

image, negative self-concept and food is strongly related to eating pathol-

ogy
(Dobson & Dozois, 2004; Eldredge & Agras, 1996;
Faunce, 2002;
Lazarus

& Galassi,
1994; Lingswiler, Crowther, & Stephens, 1989;
Marcus, Wing,

& Hopkins,
1988; Nauta, Hospers, Kok, & Jansen, 2000;
Phelan, 1987;

Powell & Thelen, 1996; Ricciardelli, Williams, & Finemore, 2001;
Shafran, Lee, Cooper, Palmer, & Fairburn,
2007).
In fact, eating pathology is often
266

Ruth Q. Wolever and Jennifer L. Best

rooted in a narrow and rigidly held (or highly accessible) self-concept cen-

tered on body weight and shape (e.g.,
APA
,
2000;
Dunkley & Grilo, 2007;

Farchaus Stein, 1996;
Hrabosky, Masheb, White & Grilo, 2007).
Individuals with ED are known to have low self-esteem (e.g.,
Jacobi et al., 2004)

and tend to hold maladaptive core beliefs about the self and interpersonal

relatedness
(Dingemans, Spinhoven, & van Furth, 2006;
Hughes, Hamill, van Gerko, Lockwood, & Waller,
2006;
Leung & Price, 2007).
To complicate this tendency, those with BN and BED demonstrate a selective attentional bias

for cues threatening to self-concept
(Jansen, Nederkoorn, & Mulkens, 2005;

Meyer, Waller, & Watson, 2000).
With attention consistently directed toward undermining thoughts, they are subsequently inclined to binge or purge as a

means of avoiding or escaping prolonged exposure to them
(Lingswiler et al.,

1989,
Powell & Thelen, 1996;
Spranger, Waller & Bryant-Waugh, 2001).
This is true even in at-risk samples, and even when the threat to self-concept

is subliminal (e.g.,
Waller & Mijatovich
,
1998;
Meyer & Waller, 1999).
Furthermore, physiological states appear to impact these avoidance tendencies;

the degree of fasting influenced selective attentional biases in women with

greater self-reported eating pathology. They showed a greater attentional bias

for low calorie words when in a non-fasting state and demonstrated an oppo-

site attentional pattern when food deprived (Placanica, Faunce & Soames

Job,
2002).

Explanation of the above findings is most easily understood through the

paradoxical relationship of rumination and thought suppression. Rumina-

tion is a perseverative cognitive process in which attention is focused on

replaying upsetting events in the mind and/or on a repetitive stream of

negative self-critical cognitions
(Nolen-Hoeksema, 2000)
in an often unsuccessful attempt to avoid intense negative affect (see
Gross, 1998
for a discussion) and make meaning out of situations when important goals have

not been attained
(Martin, Tesser, & McIntosh, 1993).
Thought suppression is a covert self-regulatory behavior used to limit exposure to upsetting

thoughts and images
(Wegner, 1994).
However, chronic attempts to suppress unwanted private events ironically elicit a rebound effect whereby the disturbing image or thought becomes more intrusive (i.e., the white bear phe-

nomenon;
Wegner, 1994).
In such cases, rumination may be characterized as a “failure” of thought suppression wherein attention becomes fixated on the

very unpleasant cognitions one would prefer to avoid. Hence, the more one

suppresses thoughts of food or negative self-concept, the more one focuses

on food or negative self-concept. Presumably, this impaired ability to con-

sciously shift attention toward or away from certain cognitive content is

mediated by being overly invested in the believability of such thoughts. Binge

eating and compensatory behaviors thus appear to function as behavioral

attempts to suppress and control upsetting or negative thoughts. However,

no research to date has directly examined a mental control model of eating

pathology.

Rationale for Mindfulness Approaches Based on the

Cognition-Behavior Interplay

Mindfulness is clearly appropriate to address the entrenched interplay

(release the rigid lock) between rigid cognitive processes and dysfunctional

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

267

behavior seen in ED. Mindfulness training can simultaneously: (1) cultivate a

nonjudgmental and accepting attitude
(Kabat-Zinn, 1994);
(2) provide more conscious control of attention
(Jha, Krompinger & Baime, 2007);
and (3) demonstrate that thoughts are just thoughts. Mindfulness is a quality of attention, in which a person intentionally brings nonjudgmental awareness to his

or her present moment experience (i.e., thoughts, feelings and physical sen-

sations) with willingness, curiosity and acceptance of what is
(Kabat-Zinn,

1994).
Theoretically, the more one practices, the more one develops this nonjudgment or acceptance. Acceptance is conceptualized as a dynamic

process of self-affirmation or self-validation composed of cognitive, affective

and behavioral components
(Linehan, 1993a;
Wilson, 1996;
Hayes, Strosahl,

& Wilson,
1999).
When an individual is consciously accepting of his or her internal experience, this “discerning wakefulness” ironically provides

enhanced control over responding to experience flexibly and adaptively

rather than impulsively or rigidly
(Kabat-Zinn, 1994).

Most recently, Bishop and colleagues have proposed a two-component

model in operationalizing mindfulness which includes adopting an accept-

ing orientation to experience as well as self-regulation of attention
(Lau et al.,

2006).
This training in attention can help individuals with ED shift their attention from food, body image and negative self-concept to more adaptive con-

tent by helping them to disengage from such content rather than suppress it.

Mindfulness practice teaches one to observe thoughts from a distance, and

recognize that thoughts are just thoughts, mental events that may or may not

have any basis in reality. Self-critical automatic thoughts thus become “men-

tal events” to be neutrally observed rather than truths to be automatically

believed.

Consistent with a stress reactivity model
(Kabat-Zinn, 1990),
mindfulness provides a rich opportunity for learning. Enhanced by taking a nonjudgmental, observer stance, individuals are taught to unbundle the wealth of infor-

mation about the stress experience obtained from emotions, thoughts, and

physical sensations that drive behavior. They have the opportunity to sep-

arate each component of the stress reaction (e.g., physiological cue about

mood versus appetite cue) and develop an internal guide (“inner compass”)

as to how to use the information gained in a conscious and adaptive way

(Wolever, Ladden, Davis, Best, Greeson, & Baime, 2007).

In addition, when mindfulness is directly applied to eating, participants

are trained to direct attention to the full sensory experience of eating and

satiety. They learn to approach eating in a more relaxed, nonjudgmental

way, and improve registration of appetite regulation cues. The latter involves

both reducing the misappraisal of internal physical states and becoming

more attuned to utilizing physiological appetite cues for initiating and ending

the eating period. Finally, mindfulness-based approaches may further lay the

ground work for adopting a more fluid and expansive sense of self and for

engaging in more self-accepting behaviors among patients with ED.

Thus, mindfulness is viewed as a self-regulatory process through which

individuals hone their
capacity to attend to
the constant stream of thoughts,

emotions and physical sensations as well as hone their capacity to alter

their
orientation and relationship to their experience
. This self-regulatory

process actually functions as a powerful learning paradigm in which indi-

viduals become their own empowered experts in interrupting personal

268

Ruth Q. Wolever and Jennifer L. Best

dysfunctional self-regulatory processes, allowing a shift in entrenched pat-

terns. This promising rationale is now being tested empirically in an emerg-

ing body of research that has found preliminary evidence for the efficacy

of mindfulness-based programs in reducing the core symptoms of ED. That

said, empirical clarification of the mechanisms of action in these approaches

is still in its infancy.

Mindfulness-based Interventions for Eating Disorders:

The Current State of the Evidence

Eating disorders are complex syndromes representing both specific and gen-

eralized deficits in self-regulation. These conditions frequently persist even in

the face of significant deterioration in psychological and physiological well-

ness. Given the increasing prevalence of ED coupled with the associated high

risk of relapse and concurrent psychopathology, greater attention is war-

ranted to improve the efficacy of existing treatments. In response to this

growing need, four innovative mindfulness-based therapeutic approaches

have been blended with traditional cognitive-behavioral theory: Dialecti-

cal Behavior Therapy (DBT;
Linehan, 1993a),
Acceptance and Commitment

Therapy (ACT;
Hayes et al., 1999),
Mindfulness-based Cognitive Therapy

(MBCT;
Segal, Williams, & Teasdale, 2002;
Baer, Fischer, & Huss, 2006),
and Mindfulness-Based Eating Awareness Training (MB-EAT; Kristeller, Baer, &

Quillian-Wolever,
2006; Kristeller & Hallett, 1999).

Dialectical Behavior Therapy (DBT)

DBT was first introduced in the early 1990’s to improve the self-regulation

deficits in borderline personality disorder (BPD)
(Linehan, 1993a).
DBT

helps patients cultivate core mindfulness abilities in conjunction with other

emotion regulation, interpersonal effectiveness, and distress tolerance skills

(Linehan, 1993b).F
rom an empirical standpoint, DBT has had an encouraging impact on improving clinical symptomatology in BPD (Linehan, Armstrong,

Suarez, Allmond et al.,
1991; Linehan, 1993a)
and is the most extensively studied mindfulness-based approach within eating disorder samples. In a

seminal analysis,
Telch (1997)
presented an in-depth case study of adapting DBT for an obese woman with BED. The 23-session intervention (i.e., 19

weekly meetings and 4 monthly meetings) was structured to include three