Re-thinking mindfulness during mealtimes in ED treatment
In psychology, mindfulness is a really hot topic. It’s everywhere, and plenty of research is showing that it can be helpful in managing anxiety, depression, and many of the other woes of modern living. Not surprisingly, mindfulness has also become extremely popular in the eating disorder field. We need to learn how to “be in the moment” and practice how to be a neutral observer in our own lives. While I have personally found the latter half of that to be extremely useful, the evidence supporting the use of mindfulness in EDs, especially AN, is much more limited. Lots of clinicians and treatment programs say they use mindfulness as a treatment philosophy and protocol.
The question is does it work, and, if so, for whom? Some ED psychologists decided to ask this question, and looked at the efficacy of pre- and during-meal mindfulness in ED patients who were in a day treatment program. They found that mindfulness isn’t always the best way to help people during the refeeding process (Marek et al., 2013).
Giving mind to mindfulness
We throw around the term “mindfulness” like it’s self-evident. It’s not. How mindfulness is used colloquially may not precisely reflect what psychologists mean when they use the term. In a semi-recent consensus statement (Bishop et al., 2004), psychologists wrote that mindfulness is
a process of regulating attention in order to bring a quality of nonelaborative awareness to current experience and a quality of relating to one’s experience within an orientation of curiosity, experiential openness, and acceptance. We further see mindfulness as a process of gaining insight into the nature of one’s mind and the adoption of a de-centered perspective on thoughts and feelings so that they can be experienced in terms of their subjectivity (versus their necessary validity) and transient nature (versus their permanence).
Given that many people with EDs are extremely self-judgemental (I think I’m CEO of this club) and try desperately to alter their feelings and internal experiences (because they are uncomfortable or bad or whatever), mindfulness was seen as a really good way to get at these symptoms. Most of the work on mindfulness has been focused on binge eating disorder and bulimia. When you’re binge eating, you’re probably not being mindful of what you’re eating and how you’re feeling. For many people, this is the whole point of binge eating.
If people practice more mindful eating, the theory goes, they will be less likely to binge and perhaps not feel so awful when they’re done eating. Although some of the results are mixed, and not all of the data is really strong and needs to be replicated, mindfulness-based treatments do appear promising for these disorders. It is also being trialed in obesity treatments with some success as well. But these results don’t necessarily indicate that mindfulness always works for every ED diagnosis.
What the study found
In a study involving 17 female ED patients in a day treatment program and 23 healthy controls, Ryan Marek and colleagues divided each group in two. Half of the study participants received pre-meal distraction training followed by mindfulness training. The other group was the reverse: mindfulness followed by distraction. The study participants were also asked to complete questionnaires measuring their current mood (i.e., sadness, fear, shame, joy, disgust, depressed, anxious, anger, excitement), as well as their current hunger and fullness. The participants also completed surveys about how well they liked the treatment.
Of the ED patients, 1 had AN, 8 had BN, and 8 had EDNOS. Both the EDNOS and AN group in this study had primarily restrictive symptoms. The groups ate a piece of blueberry coffee cake and completed the mood questionnaires both before and after eating. This was repeated for each training module (so the participants ate two pieces of cake over the course of the study).
For the healthy controls, mindfulness training significantly decreased negative mood post-meal. For the eating disorder group, however, this effect was actually worse: depression went up after mindfulness training vs. distraction. The ED group also liked the mindfulness training significantly less than the control group.
The authors wrote:
Given that mindful eating is used to assist patients in attending to feelings of hunger and satiety these findings are perhaps not surprising. Because many ED clients are in a chronic state of self-starvation, their hunger/satiety cues are often impaired. Subsequently, these individuals report excessive fullness, bloating, and abdominal pain after consuming small amounts of food. Thus, for those in the clinical sample, mindful attention to the physical sensation of fullness may have been iatrogenic.
For me, distraction was a lifesaver when getting through meals. The more I thought about what I was eating and how full I was, the harder it became. Focusing on it would have been a disaster.
Still, I think we can get too dependent on distraction as a crutch. There’s nothing wrong with paying attention to your meal, and it probably does help you enjoy it more. Needing to read, do puzzles, or watch TV isn’t good, either. But if the focus is just on getting the food down and keeping it down, or on including more foods in your diet, then distraction may be a good way to get those things done. You can work on mindfulness later.
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z. V., Abbey, S., Speca, M., Velting, D. and Devins, G. (2004), Mindfulness: A Proposed Operational Definition. Clinical Psychology: Science and Practice, 11: 230–241. doi: 10.1093/clipsy.bph077
Marek, R. J., Ben-Porath, D. D., Federici, A., Wisniewski, L. and Warren, M. (2013), Targeting premeal anxiety in eating disordered clients and normal controls: A preliminary investigation into the use of mindful eating vs. distraction during food exposure. Int. J. Eat. Disord. doi: 10.1002/eat.22152