Clinical Handbook of Mindfulness (79 page)

change; they mindfully center themselves and remember why the change

matters in the long run
(Wolever et al., 2007).
This approach is further aided by strategies for setting
S
pecific,
M
easurable,
A
ction-oriented,
R
ealistic and
T
ime-bound (SMART) short and long-term goals. While it remains an empirical question, clinical experience suggests that these additional tools signifi-

cantly augment the mindfulness approach and vice versa.

The choice to add additional tools to mindfulness treatment may depend

in part on the level of mindfulness practice that individuals are willing to

undertake, and their ability to create an environment conducive to internal

listening. Given the practical reality of most clients’ lives, and the fact that

these approaches may benefit many people that are not drawn to medita-

tion per se, it may be wise to use mindfulness to create a learning space to

enhance wise decision making in a more active fashion as well. For example,

when one is deciding whether or not to eat, it is useful to reference physio-

logical hunger cues rather than external signals that it is time to eat (food is

present, meal break begins, etc.). Similarly, when deciding to stop eating, it is

useful to register physiological cues of moderate fullness rather than external

cues that eating is complete (clean plate, time is up, etc.). However, Western

culture is so externally driven and fast-paced, it is often not enough to teach

clients to pay attention to hunger and fullness. They must also carefully plan

to establish an environment in which they can register these signals; and this

requires assertiveness and other traditional techniques. For instance, imag-

ine that you are a nurse working a 12 hour shift without a meal break. While

physiologically, it is important to eat during your shift, the health system

does not build in time for this task. The nurse must use assertiveness skills to

assure even a 15 minutes break to eat, as well as flexibility to sense the best

time to take the break, as well as planning and preparation to ensure that

nutritious food is available in small quickly-edible portions. Similarly, regis-

tering moderate hunger and moderate fullness signals after the work shift

may help the nurse avoid overeating after work, but some nutritious intake

during the shift will also help avoid overeating later.

In such situations, mindfulness helps participants to create an optimum

learning space, and the introduction of concepts and tools from other tra-

ditional approaches may strengthen the intervention. For example, state

of the art treatments for bulimia and BED (e.g.,
Apple & Agras, 1997;

Fairburn, 1995)
encourage participants to recognize and label thoughts and emotions that precede bingeing. Mindfulness, however, can facilitate this

learning by applying a layer of nonjudgment to remove harsh criticism (from

self or others), freeing up participants for more accurate self-observation.

One significant difference in these approaches and mindfulness-informed

approaches, however, is that CBT encourages direct intervention into the

thoughts or behaviors whereas pure mindfulness suggests that just observing

the thought, emotion, or sensation is enough; the mere process of nonjudg-

mentally attending to them allows for a shift from within the participant.

In sum, participants with ED are driven by deficits in the self-regulation

of food intake, emotion and cognition. There is strong theoretical support

280

Ruth Q. Wolever and Jennifer L. Best

for the application of mindfulness to this dysregulation, and an emerging

literature on its efficacy. Some approaches use more traditional MBSR tech-

niques while others apply these mindfulness techniques directly to eat-

ing and compensatory mechanisms characteristic of ED. The EMPOWER

approach conceptualizes mindfulness as a strong self-learning tool in which

individuals explore new ways to self-regulate; some ways are taught through

pure mindfulness whereas others apply mindfulness to other behavior

change techniques (e.g., goal-setting). Additional research will be important

in evaluating the efficacy of various aspects of mindfulness-based treatments

in treating specific issues.

Acknowledgements:
The authors wish to thank and acknowledge Jean

Kristeller, PhD, Sasha Loring, MEd, LCSW, Michael Baime, MD and Larry Lad-

den, PhD whose wise attention to the application of mindfulness has deeply

informed our work.

References

Agras, W. S. & Telch, C. F. (1998). The effects of caloric deprivation and negative affect

on binge eating in obese binge-eating disordered women.
Behavior Therapy, 29
,

491–503.

Allen, H. N. & Craighead, L. W. (1999). Appetite monitoring in the treatment of binge

eating disorder.
Behavior Therapy, 30
, 253–272.

American Psychiatric Association. (1994).
Diagnostic and Statistical Manual of Men-

tal Disorders
(DSM-IV, 4th ed.). Washington, D.C.: American Psychiatric Press.

American Psychiatric Association. (2000).
Diagnostic and Statistical Manual of Men-

tal Disorders
(DSM-IV, 4th ed. Text revision). Washington, D.C.: American Psychi-

atric Press.

American Psychiatric Association Work Group on Eating Disorders. (2000). Practice

guideline for the treatment of patients with eating disorders (revision).
American

Journal of Psychiatry, 157
(1), 1–39.

Apple, R. F. & Agras, W. S. (1997). Overcoming Eating Disorders: A Cognitive-

Behavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. Graywind

Publications, Inc.

Baer, R. A., Fischer, S., & Huss, D. B. (2005). Mindfulness-based cognitive therapy

applied to binge eating: A case study.
Cognitive and Behavioral Practice, 12
,

351–358.

Baer, R. A., Fischer, S., & Huss, D. B. (2006). Mindfulness and acceptance in the treat-

ment of disordered eating.
Journal of Rational-Emotive & Cognitive-Behavior

Therapy, 23
, 281–300.

Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E.,

Uppala, S., & Simonich, H., et al. (2007). Perfectionism and eating disorders: Cur-

rent status and future directions.
Clinical Psychology Review, 27
, 384–405.

Becker, A. E., Keel, P., Anderson-Fye, E. P., & Thomas, J. J. (2004). Genes and/or jeans?:

Genetic and socio-cultural contributions to risk for eating disorders.
Journal of

Addictive Diseases, 23
, 81–103.

Berkman, N. D., Lohr, K. N., & Bulik, C. M. (2007). Outcomes of eating disorders: A

systematic review of the literature.
International Journal of Eating Disorders, 40
,

293–309.

Berthoz, S., Perdereau, F., Godart, N., Corcos, M., & Haviland, M. G. (2007). Observer-

and self-rated alexithymia in eating disorder patients: Levels and correspondence

among three measures.
Journal of Psychosomatic Research, 62
, 341–347.

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

281

Bowers, W. A. (2002). Cognitive therapy for anorexia nervosa.
Cognitive and Behav-

ioral Practice, 9
, 247–253.

Brandsma, L. (2007). Eating disorders across the lifespan.
Journal of Women and

Aging, 19
, 155–172.

Brownley, K. A., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007).

Binge eating disorder treatment: A systematic review of randomized controlled tri-

als.
International Journal of Eating Disorders, 40
, 337–348.

Bruce, B. & Agras, W. S. (1992). Binge eating in females: A population-based investi-

gation.
International Journal of Eating Disorders, 12
, 365–373.

Bulik, C. M., Berkman, N. D., Brownley, K. A., Sedway, J. A., & Lohr, K. N. (2007).

Anorexia nervosa treatment: A systematic review of randomized controlled trials.

International Journal of Eating Disorders, 40
, 310–320.

Bydlowski, S., Corcos, M., Jeammet, P., Paterniti, S., Berthoz, S., Laurier, C., Chambry,

S., & Consoli, S.M. (2005). Emotion-processing deficits in eating disorders.
Interna-

tional Journal of Eating Disorders, 37
, 321–329.

Cachelin, F.M., Striegel-Moore, R. H., Elder, K. A., Pike, K. M., Wilfley, D. E., & Fairburn,

C. G. (1999). Natural course of a community sample of women with binge eating

disorder.
International Journal of Eating Disorders, 25
, 45–54.

Carano, A., De Berardis, D., Gambi, F., Di Paolo, C., Campanella, D., & Pelusi, L. (2006).

Alexithymia and body image in adult outpatients with binge eating disorder.
Inter-

national Journal of Eating Disorders, 39
, 332–340.

Cash, T. F. & Deagle, E. A. (1997). The nature and extent of body image disturbances

in anorexia nervosa and bulimia nervosa: A meta-analysis.
International Journal of

Eating Disorders, 22
, 107–125.

Claes, L., Vandereycken, W., & Vertommen, H. (2005). Impulsivity-related traits in

eating disorder patients.
Personality and Individual Differences
,
39(4)
, 739–749

Corstorphine, E. (2006). Cognitive-emotional-behavioral therapy for the eating disor-

ders: Working with beliefs about emotions.
European Eating Disorders Review,

14
, 448–461.

Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., & Meyer, C. (2007). Distress

tolerance in the eating disorders.
Eating Behaviors, 8
, 91–97.

Corstorphine, E., Waller, G., Ohanian, V., & Baker, M. (2006). Changes in internal

states across the binge-vomit cycle in bulimia nervosa.
Journal of Nervous and

Mental Disease, 194
, 446–449.

Craighead, L. W. & Allen, H. N. (1995). Appetite awareness training: A cognitive

behavioral intervention for binge eating.
Cognitive and Behavioral Practice, 2
,

249–270.

Dalle Grave, R., Di Pauli, D., Sartirana, M., Calugi, S., & Shafran, R. (2007). The

interpretation of symptoms of starvation/severe dietary restraint in eating disorder

patients.
Eating and Weight Disorders, 12
, 108–113.

Davis, R. & Jamieson, J. (2005). Assessing the functional nature of binge eating in the

eating disorders.
Eating Behaviors, 6
, 345–354.

Deaver, C. M., Miltenberger, R. G., Smyth, J., Meidinger, A., & Crosby, R. (2003). An

evaluation of affect in binge eating.
Behavior Modification, 27
, 578–599.

Dingemans, A. E., Spinhoven, Ph., & van Furth, E. F. (2006). Maladaptive core beliefs

and eating disorder symptoms.
Eating Behaviors, 7
, 258–265.

Dobson, K. S. & Dozois, D. J. A. (2004). Attentional biases in eating disorders:

A meta-analytic review of Stroop performance.
Clinical Psychology Review, 23
,

1001–1022.

Dunkley, D. M. & Grilo, C. M. (2007). Self-criticism, low self-esteem, depressive symp-

toms, and over-evaluation of shape and weight in binge eating disorder patients.

Behaviour Research and Therapy, 45
, 139–149.

Eldredge, K. L. & Agras, W. S. (1996). Weight and shape overconcern and emotional

eating in binge eating disorder.
International Journal of Eating Disorders,

19
, 73–82.

282

Ruth Q. Wolever and Jennifer L. Best

Fairburn, C. G. (1995).
Overcoming binge eating
. New York: Guildford Press.

Fairburn, C. G., Cooper, Z., Doll, H. A., Norman, P., & O’Connor, M. (2000). The

natural course of bulimia nervosa and binge eating disorder in young women.

Archives of General Psychiatry, 57
, 659–665.

Farchaus Stein, K. (1996). The self-schema model: A theoretical approach to the

self-concept in eating disorders.
Archives of Psychiatric Nursing, 10
, 96–109.

Faris, P. L., Eckert, E. D., Kim, S. W., Meller, W. H., Pardo, J. V., Goodale, R. L., & Hart-

man, B. K. (2006). Evidence for a vagal pathophysiology for bulimia nervosa and the

accompanying depressive symptoms.
Journal of Affective Disorders, 92
, 79–90.

Fassino, S., Piero, A., Gramaglia, C., & Abbate-Daga, G. (2004). Clinical, psychopatho-

logical and personality correlates of interoceptive awareness in anorexia nervosa,

bulimia nervosa and obesity.
Psychopathology, 37
, 168–174.

Faunce, G. J. (2002). Eating disorders and attentional bias: A review.
Eating Disorders,

10
, 125–139.

Felker, K. R. & Stivers, C. (1994). The relationship of gender and family environment

to eating disorder risk in adolescence.
Adolescence, 29
, 821–834.

Fernandez-Aranda, F., Pinheiro, A. P., Thornton, L. M., Berrettini, W. H., Crow, S.,

Fichter, M. M., Halmi, K. A., Kaplan, A. S., Keel, D., Mitchell, J., Rotondo, A.,

Woodside, D. B., Kaye, W. H. & Bulik, C. M. (2008). Impulse control disorders in

women with eating disorders.
Psychiatry Research, 157
, 147–157.

Fichter, M. M., Quadflieg, N., & Gnutzmann, A. (1998). Binge eating disorder:

Treatment outcome over a 6-year course.
Journal of Psychosomatic Research, 44
,