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.

mindfulness intervention

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.

References:

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

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13 Responses to “Re-thinking mindfulness during mealtimes in ED treatment”

  1. This reflects one of the biggest fights I had w/my treatment team. My dietitian said “healthy eating takes place in the kitchen at a table, not in front of a computer screen” and my therapist agreed. I yelled the same thing at them both: “FUCK THAT.”

    My reason is simple: if the goal is to get x amount of food into my body, and getting x amount in causes nausea, panic, gagging, and tears, and messing around on the computer while eating helps to decrease those reactions and increase the likelihood of success for said goal, then this must then be acceptable. Period. And shut the hell up about whether or not that’s “healthy eating.” I also reminded them that OF COURSE it’s not a normal way to have to eat- I’m not stupid- I KNOW this- I have an eating disorder for God’s sake- why would you expect me to eat “normally”?!! I’m eating- and for now that has got to be enough.

    They have dropped that line of thinking completely with me- I guess I made a strong case.

    The other thing is that it is completely unfair (and unrealistic) for a dietitian to hold an ed client up to her personal expectations of “normalcy.” I mean, seriously, here’s this woman who loves food so fucking much she actually made it her fucking LIFE CAREER- and she’s sitting here all smug and confident in her comfortable chair, telling me I shouldn’t be distracting myself while I eat. That SO incited my rage. Do you have panic attacks when you eat? Do you gag when you try to swallow? Do you struggle with not bursting into tears over your dinner in front of your children? Does your stomach lurch? Do your hands shake? NO??!!!? Then you cannot ever fucking understand me- and don’t you DARE tell me it’s wrong to distract myself from all that pain that you will never, ever understand. Don’t even tell me it’s “not healthy.” Don’t say a fucking word about it. Just do your fucking job and tell me what to eat- and leave me the fuck alone as to how I do it.

    • P.S. I should add that mindfulness OUTSIDE of the actual sitting down and eating part of recovery has actually been very helpful. I’m not at all against mindfulness in general. Only that, while eating, it is absolutely useless for me. Distraction is the only thing that has helped. Mindfulness while eating (for me) would be as stupid as telling my child to consider how foul the medicine tastes before he swallows it rather than advising him to hold his nose and just gulp it down quickly.

  2. I tend to agree that distraction is probably better for some people in terms of getting the food in without the anxiety getting out of control. That being said, I think that mindfulness can be very useful in regards to the “runaway fears” that plague a lot of us with EDs—”omg if I eat this I will gain X which is almost Y which will put my weight at ZZZ which is almost ZZZ+10 and the number will go up forever” etc. When we keep our thoughts grounded in the moment, it’s harder to rationalize those vague, never ending, usually baseless anxieties. In my own recovery, actual weight gain was the only thing that really reduced my anxiety about gaining weight, but once weight-restored I have been much better able to approach things “mindfully”—I don’t know if that would have been possible when I was underweight and nuts.

  3. Kelsey Wallour June 15, 2013 at 7:23 pm

    Awesome post, thanks for covering this! I originally wanted to do my thesis project on mindful eating and eating disorders, but to get done in the amount of time I needed to that wasn’t feasible. So I am doing my thesis on the effectiveness of mindful eating in assisting overweight/obese with appetite regulation. General mindfulness and mindful eating are really hot topics, but really well-conducted studies are a rarity, which was really frustrating.
    But I suppose in terms of eating disorders, this is maybe a step on the continuum toward more healthy eating habits. Then again, I don’t think it is necessarily a step that all recovering patients need to take. Anecdotally mindfulness sounds great, but it just doesn’t seem to always play out as expected, and people need to prioritize and pick their battles!
    P.S. Thanks for all the great work you do – keep it up 🙂

  4. I am a huge fan of mindfulness in general, but when it comes to eating, I am all for distraction. My team agrees, which makes my life a bit easier. I get that an ultimate, long term goal could be to eat truly mindfully, but when it comes to figuring out how to feed yourself again (where I’m at), I rely on pairing meals with enjoyable, distracting activities (internet, TV, books). My dietish pointed out that the distraction isn’t necessarily bad. She thinks it could help to pair eating with an enjoyable activity so that there’s SOME reason to look forward to meal times. For instance, I always eat Sunday breakfast while reading PostSecret and I actually look forward to it.

    All that said, learning mindfulness based skills in DBT has made the rest of my life a lot better. Go mindfulness! 😉

  5. Is it possible to engage in “mindful distraction?” When I’m particularly anxious around a meal or snack, I (try) to acknowledge whatever feelings – physical and/or emotional – and intentionally engage in distraction. I try to practice mindfulness in other areas of my life so that one day I can practice mindfulness around eating too. I’m not sure if that works for everyone, but it has definitely helped me.

    • Actually, that sounds like a brilliant idea. It’s one thing to, say, watch TV without really paying attention to your program. It’s another to actually sit down and watch a show. TV itself is fairly mindless, but doing it with intention is probably better.

      It’s something similar with eating. Being aware that you’re distracting yourself is fine, and doing so deliberately. It’s another to just totally check out all the time.

  6. Personally, mindfulness was the first thing to have a genuine and lasting positive effect on my recovery. However, I agree with the other commentators that practicing mindfulness during eating would be counterproductive at best. The therapist who introduced me to mindfulness never even suggested doing that (maybe she knew that just the thought of it would give me anxiety). She encouraged me to try it during parts of the day when I felt, or expected, to feel anxiety, whether or not food-related, and especially when I started to feel guilty after eating. That was the part that was helpful. I’ve imputed my ED with so much meaning over the years, and learned to derive my identity from my ED behaviors (I’m a disciplined, conscientious, careful, etc. person) and mindfulness was the first thing that has finally given me a way to start to let go of that kind of thinking. Rather than thinking of eating or not eating as either good or bad and taking it to mean something about who I am as a person, I’m learning to tell myself that it means absolutely nothing. For me, that’s an enormous burden off of my shoulders.

  7. It’s funny because when I read another article about this study, my first thought was, “Well, the research has caught up with my treatment center, once again!” lol The providers at my treatment center (The Center for Balanced Living – a la Dr. Laura Hill, whom you’ve written about before) have been arguing this for years.

    That said, promoting certain kinds of distraction for certain clients during mealtimes is very different than re-thinking mindfulness in ed treatment! That’s a much, much broader claim, and I don’t think it’s the argument that this article is making. It’s certainly not the argument at my treatment center – where mindfulness is really stressed overall, and we focus on other skills when mindfulness may not be the most effective one.

  8. Lisa Williams West June 19, 2013 at 9:04 am

    I think that mindful distraction during meal times is great and perhaps the best.

    A lot of programs claim to use “mindfulness” yet it IS a colloquial technique largely unregulated. The type of mindfulness MBSR that I know of, is quite different from what was describled in the piece and has a large basis of applicability for other uses. MBSR Mindfulness is characterized by nonevaluative and sustained moment-to-moment awareness of perceptible mental states and processes. MBSR Mindfulness is nondeliberative: It implies noticing ongoing mental content without thinking about, comparing or in other ways evaluating it.

    So getting back to the study (which was tiny by the way, 17 participants 23 control) How was mindfulness taught? Its like saying Yoga has been found not to be helpful. Well what kind of yoga, taught by whom?

    I wouldn’t toss the towel in on mindfulness especially MBSR in early refeeding, but like everything else get thee to a qualified clinician who has the empathy and clinical skills necessary to deliver.

  9. Mindfulness has been a godsend for my anxiety. Ive kinda noticed it isnt too great with refeeding. Im glad something that doesnt work for one issue but works for another can still be incorporated into my life 🙂