Clinical Handbook of Mindfulness (77 page)

9. to make a wise and informed decision about addressing this true need.

Skill Set 1: Nonjudgmental observation of reactivity
– As a starting

place, individuals with ED need to develop skills in shifting attention to

internal states in order to observe emotion, cognition and sensation, and

the way these interact to drive behavior. Most participants initially struggle

to center their attention on internal states, and mindfulness training can best

be described as a learning paradigm that allows individuals to become their

own experts and advocates. Nonjudgment is seminal in creating this learn-

ing environment allowing individuals to explore their patterns with lowered

defenses. They often express surprise when they sample nonjudgment. It

is also common for participants to cry during their first practice of forgive-

ness meditation when asked to consider forgiving themselves for mistakes

made, or unhealthy behaviors performed; many clients have just “never con-

sidered this.” Some participants initially experience anxiety at the idea of for-

giving themselves because they believe that sharp self-judgment gives them

a greater sense of control. In addition, further attention is needed to explore

the fine line between accountability and judgment when using mindfulness

to support behavior change of any kind ( Table
14.1).

Skill Set 2: Separating Out Emotions
– Individuals need to demonstrate

a willingness to accept emotional experience (including changes in physio-

logical arousal) reassured by the understanding that emotions are transient

events
(Linehan, 1993b;
Gratz & Gunderson, 2006)
and that one does not have to react to them. It is actually the process of engaging emotions that

can elongate their presence. Regular sitting meditation practice strengthens

this learning and may include guidance such as:

If you notice that your mind wanders away or your attention is pulled by

an emotion, just observe what that is
. . .
whatever feelings are present are

fine
. . .
and you don’t have to do anything about them
. . .
just observing them

without judging them
. . .
just noticing whatever you are experiencing
. . .
not

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

273

Table 14.1.
Nine core skill sets enhanced by mindfulness approaches that

are seminal to recovery from eating disorders.

Nine core skill sets in the EMPOWER approach

1. nonjudgmental observation of reactivity (bundle of thoughts, emotions, and body

sensations that drive behavior)

2. separation of emotions from this bundle and learning that emotions are transient

events that often do not require response

3. separation of thoughts from this bundle of reactivity, and learning that thoughts

are just thoughts, transient events that often do not require response

4. separation and tolerance of behavioral urges from this bundle of reactivity

5. clarification of physiological signals of hunger and fullness (gastric satiety)

6. attention to taste-specific satiety

7. discernment of the physiological signature of emotions and appetite regulation

cues

8. discernment of the true need underlying the reactivity

9. wise and informed decision making to address the true need

trying to change it, but just noticing it
. . .
whatever you experience is fine
. . .
just notice it, whatever it is
. . .
you may even find that emotions come and they

go
. . .
like leaves in a river floating downstream
. . .
you can observe them arrive and pass without engaging them
. . .
and if you find yourself floating downstream

with the leaves, you can climb back onto the bank of the river and watch again

as the leaves float downstream
. . .

The next step is then to sit with the emotion from a more accepting stance.

Accurately registering such signals allows one to explore what true need

exists that is driving unhealthy behavior (e.g., eating due to physical hunger,

to self-soothe anxiety, or to stay awake because exhausted). For the past year,

we have been teaching clients a tool called Stop-Breathe-Feel
(Wolever et al.,

2007),
a tool that teaches them to recognize without judgment the emo-

tion present and understand that eating (or compensatory behavior) will not

address the real need. For example, if one eats to manage anxiety, the cues

of hunger are less relevant because the goal of eating is to manage anxiety.

We encourage clients to catch the information from the body early on and

apply mindfulness; just notice the anxiety and recognize that the issue gen-

erating anxiety is not likely to be managed by eating. Rather, the emotion is

just a tool in the decision-making process about how to handle the real need

(whatever is triggering the anxiety). The more we become okay with recog-

nizing the importance of emotions as tools in the decision-making process,

the less afraid we will be when they arise in the moment. In fact, acceptance

itself has been described as “actively responding to feelings by allowing or

letting be before rushing in and trying to fix or change them. Allowing means

that participants register their presence before deciding how to respond to

them”
(Segal, Williams, & Teasdale, 2002).
Most clients experience this simple Stop-Breathe-Feel tool as powerful: just deciding to stop, breathe and

allow oneself to feel whatever is present in that moment without avoidance

strengthens confidence. We use the metaphor of riding on a train: one aim

of this program is to develop a certain kind of attention so one can identify

the right stop (e.g., directly observe the emotional cue from a nonreactive

stance). However, when we miss our stop, we can still work back. So, when

the emotional cue is missed, we may catch ourselves riding to another stop

274

Ruth Q. Wolever and Jennifer L. Best

(e.g., bingeing or engaging in compensatory behavior) and retrace our steps

in how we arrived there.

Skill Set 3: Separating Out Thoughts
– Traditional mindfulness

approaches are excellent at helping participants learn that thoughts are just

thoughts, mental events that do not necessarily have any basis in reality. This

is a powerful recognition for participants with ED whose thoughts are fused

with behavioral and emotional patterns. One 33 year old obese female with

BED felt significantly empowered when she, on her own, came to the real-

ization that “I want to eat’ is just a thought;” I don’t have to respond to it.” In

addition to recognizing that thoughts are not truths, observations of the qual-

ity of thought can provide insight. For instance, participants with ED benefit

from recognizing when their thinking becomes negative. In pure mindful-

ness, nonjudgmental observation of the negative thought is enough to reduce

its power, but it remains an empirical question whether or not more support

(e.g., additional tools) is needed to help counter life-long perceptual patterns.

This question is of course confounded by the amount participants prac-

tice. Clinical experience suggests that many participants practice the shorter

techniques and attain some shifts in perspective, but may not practice

enough to re-pattern habitual thought patterns without the aid of additional

tools.

Skill Set 4: Separation and tolerance of behavioral urges
– The

behaviors of ED participants fall along a compulsive-impulsive continuum

(Claes, Vandereycken, & Vertommen, 2005; Lawson, Waller & Lockwood,

2007)
and thus learning to sit through an urge to react is important. Participants strengthen their ability to sit with behavioral urges by learning

to watch urges develop without responding to them. Instruction is woven

into weekly EMPOWER sessions that encourage observation of small urges

that are not enacted, building strength to tolerate stronger urges (Wolever

et al.,
2007).
For example, during a sitting meditation, participants are asked to note any desires to fidget or readjust their body position as well as to

observe what happens to the urge if not enacted. Similarly, during eating

meditations, participants are asked to play with the urge to swallow in a sim-

ilar way, pausing momentarily before biting or before swallowing to observe

what happens. The learning is then reinforced through specific discussion

about tolerating such urges. This tolerance serves to weaken the automatic

link between urges and reaction. Participants then benefit from using mini-

meditation
(Kristeller et al., 2006),
the Stop-Breathe-Feel technique (Wolever et al.,
2007),
and eventually 20 minutes of regular sitting practice when experiencing the urge to binge or compensate. Tolerance, and subsequently con-

fidence, is likely to develop further through nonjudgmental observation of

these urges rather than the more traditional clinical (although also useful)

approach of distracting oneself during an urge.

Skill Set 5: Recognition of hunger and fullness
– Geneen Roth’s early

clinical work (e.g.,
Roth, 1984)
was the first widespread approach to “compulsive eating” that drew attention to the importance of hunger and fullness.

MB-EAT expanded this approach by incorporating additional training on full-

ness and by contextualizing the training within mindfulness, heavily empha-

sizing nonjudgment. Registering appetite regulation cues (and emotions for

that matter) both require experience in sensing the body. This is challenging

in ED because those with more restrictive ED report such paradoxical body

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

275

sensations and those with more compulsive and impulsive ED are often dis-

sociated from somatic experience. They have many thoughts and judgments

about the body, but considerably less experience feeling its sensations. Tradi-

tional MBSR practices in body scanning techniques and gentle yoga are used

to develop this essential core skill. Since it is very difficult for participants

to maintain focus on the experience of the body, individuals with significant

dieting and/or bingeing histories also tend to have more difficulty practic-

ing the body scan than they do practicing sitting meditation. The experi-

ence of an obese 52-year-old woman with BED demonstrated how difficult

it was to center her attention on physical experience during a guided body

scan. Although she was extremely engaged in her treatment group, and vol-

unteered verbal accounts of her experience often, she could only note, “I

took this opportunity to do ankle circles (stretch her ankles)” when asked

about her experience during the body scan.

In EMPOWER, MBSR body scan techniques are then adapted to focus an

individual on sensations that cue hunger and gastric satiety (fullness). A seven

point Hunger/Fullness scale informed by the work of Craighead & Allen

(1995) provides participants the conceptual frame to rate their somatic expe-

rience of hunger and fullness. We have used the below exercises with BED

and BN patients for the past 7 years, but have no experience using them with

AN. Clinically speaking, AN clients tend to experience a sense of fullness in

the absence of food in the stomach; it is unclear if participants with AN

would benefit from this model of interoceptive awareness. They are likely to

need adjustments to this approach that focus more on tolerating the sensa-

tion of food in the body and separating out judgments from actual sensations

in the process (Figure 14.1).

BN and BED participants are reminded that the stomach is located right

below and to the left of breastbone, as many people believe it is lower and

incorrectly center attention on the intestinal area for cues. They are then

taught to center themselves and carefully attend to areas of potential sensa-

tions with instructions such as:

When you’re ready you can move your awareness to the sensations in the stom-

ach
. . .
Noticing whatever is there
. . .
You may even want to rest one of your