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Mindfulness and Acceptance in The Treatment of Ed
Mindfulness and Acceptance in The Treatment of Ed
DOI: 10.1007/s10942-005-0015-9
Author correspondence to Ruth A. Baer, Dept of Psychology, University of Kentucky, 115 Kastle
Hall, Lexington, KY, 40506-0044 USA; e-mail: rbaer@uky.edu.
EATING DISORDERS
events that begins with distorted thoughts about thinness and diet-
ing, especially in individuals with low self-esteem and concerns about
body shape and weight. Initially, these individuals perceive social or
interpersonal pressure to be thin and develop maladaptive cognitions
or beliefs about thinness. Distorted beliefs about the benefits of
thinness are hypothesized to lead to strict dieting. The resulting calo-
ric deprivation causes hunger, which increases the likelihood of binge
eating. However, because binge eating violates dietary restrictions,
binges lead to distress, guilt, lowered self-esteem, and increased con-
cerns about body shape and weight. In order to compensate for the
unwanted effects of the binge, the individual may engage in purging
behavior in the form of self-induced vomiting, laxative or diuretic
use, or excessive exercise. These behaviors typically are followed by
renewed determination to restrict food intake (Apple & Agras, 1997).
Central to this model is the hypothesis that distorted cognitions
about dieting and thinness perpetuate restriction of food and, thus,
binge eating and purging behavior. A sizable body of empirical evi-
dence supports this assertion, especially for women. Media images of
increasingly thinner women are believed to create social pressure to
be thin in order to be attractive and successful. Adoption of these
societal standards, described as thin-ideal internalization (Stice,
2002; Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004)
has been shown in experimental and longitudinal studies to lead to
increases in bulimic symptoms (Stice, 2002). In addition, Thompson
et al. (2004) reported that bulimic women endorse the thin-ideal more
strongly than non-bulimic women. Body dissatisfaction, defined as
negative subjective evaluation of physical attributes (Stice and Shaw,
2002), is also thought to increase with endorsement of the thin-ideal.
This relationship has been demonstrated in laboratory studies in
which exposure to media images of thin models leads to increased
body-focused anxiety, especially in women who endorse the thin-ideal
(Halliwell & Ditmar, 2004).
The application of expectancy theory to the study of eating disor-
ders provides additional empirical evidence for the role of distorted
cognitions in disordered eating behavior. Response outcome expectan-
cies are beliefs that a given behavior will result in a given outcome
(Bolles, 1972; MacCorquodale & Meehl, 1953; Rotter, 1954). Expec-
tancies are formed as a result of one’s learning history, either
through direct learning experiences or through modeling by others,
and are thought to be causally linked to behavior. Outcome expectan-
cies regarding thinness include ‘‘I would be more self-reliant and
Ruth A. Baer, Sarah Fischer, and Debra B. Huss
independent if I were thin,’’ and ‘‘I would feel more capable and confi-
dent if I were thin’’ (Hohlstein, Smith, & Atlas, 1998). Individuals
with AN and BN endorse outcome expectancies for thinness at much
higher rates than individuals without these disorders (Hohlstein,
et al., 1998). Furthermore, in a recent longitudinal study, Smith,
Simmons, Annus, and Hill (2005) showed that expectancies regarding
thinness predicted the development of symptoms of BN in a sample
of middle school girls.
In addition to distorted thoughts about the importance of thinness,
many individuals with eating disorders show maladaptive thoughts
about food and eating patterns. For example, many have self-imposed
rules about foods that must always be avoided (such as ice cream or
cookies). A single violation of a dietary rule may be considered a com-
plete failure of the entire diet. This thought often leads to binge eat-
ing, which increases the believability of thoughts of failure.
The importance of cognition in the initiation and maintenance of
disordered eating leads us to hypothesize that mindfulness and
acceptance-based treatment strategies would be useful in addressing
these symptoms. A goal of mindfulness training is to cultivate non-
judgmental observation and acceptance of sensations, cognitions, and
emotions. Mindfulness-based approaches typically do not include tra-
ditional cognitive therapy strategies designed to challenge or change
the content of thoughts. Instead, mindfulness training encourages a
decentered view of thoughts, in which thoughts are viewed as fluctu-
ating and transient mental events, rather than factual or accurate
representations of reality. This decentered view, also known as defu-
sion in ACT, should reduce the believability of thoughts and promote
the realization that thoughts do not necessitate specific behaviors.
For example, a client may have distorted thoughts about the conse-
quences of breaking a dietary rule, which typically would trigger
binge eating or increased restriction of eating. However, adopting a
mindful stance should facilitate the understanding that these
thoughts are transient, may be replaced with other thoughts, and do
not necessarily reflect reality or require any particular behavior, thus
reducing the client’s perceived need to take action to correct the
‘‘fact’’ that she has ‘‘blown her diet.’’
work toward valued goals and life directions. A recent clinical case
study (Heffner et al., 2002) and self-help manual (Heffner & Eifert,
2004) describe the application of ACT to anorexia nervosa. The inter-
vention includes several mindfulness and acceptance-based strategies
for working with fat-related thoughts, images, and fears. For exam-
ple, the thought parade is a mindfulness exercise in which the partic-
ipant imagines that her thoughts are written on cards carried by
marchers in the parade. Her task is to observe the parade of
thoughts, such as ‘‘I’m a whale’’ and ‘‘my stomach is gross’’ (Heffner
et al., 2002, p. 234) as they come and go, without becoming absorbed
in them, believing them, or acting on them. This exercise encourages
the nonjudgmental observation of cognitions, rather than engaging in
anorexic behaviors in reaction to such thoughts. Similarly, in the bus
driver exercise, the participant imagines that she is the driver of
a bus, which represents her movement toward valued life goals. Fat-
related thoughts are conceptualized as passengers on the bus, who
demand that she change direction and drive the bus ‘‘down the anor-
exia road’’ (Heffner et al., 2002, p. 235). This exercise encourages the
ability to allow negative thoughts to be present without acting in
accordance with them, and while maintaining movement in valued
directions. As adequate nutrition generally is required to maintain
the energy to move in these directions (such as being a good friend or
doing good work), an important feature of the intervention is the
clarification of the patient’s most important values.
Mindfulness-based eating awareness training (Kristeller & Hallett,
1999) was developed to treat binge eating disorder and is loosely
based on the Mindfulness-Based Stress Reduction (MBSR) program
develop by Kabat-Zinn (1982, 1990). It is conducted as a 9-session
group intervention and includes several types of mindfulness and
meditation exercises. Breathing and body scan meditations promote
awareness and acceptance of bodily sensations, including hunger and
satiety cues. Other exercises involve mindful eating of foods typically
included in binges, such as cookies and cake, focusing on eating
behaviors, emotions associated with eating, and the textures and
tastes of the foods eaten. Mini-meditations also are taught, in which
participants learn to stop for a few moments at key times during the
day to practice nonjudgmental awareness of thoughts and feelings.
Efficacy of MB-EAT has been supported in an uncontrolled trial
(Kristeller & Hallett, 1999) and in a recent controlled trial
(Kristeller, unpublished data).
Journal of Rational-Emotive & Cognitive-Behaviour Therapy
MBCT is derived largely from MBSR and was developed for the
prevention of relapse of major depressive episodes. Two randomized
trials have shown that MBCT substantially reduces the risk of
relapse in individuals with three or more previous episodes (Ma &
Teasdale, 2004; Teasdale, Williams, Soulsby, Segal, Ridgeway, &
Lau, 2000). Adaptation of MBCT for application with binge eating
has been described in a recent case study (Baer et al., 2005). Addi-
tional information about this approach is provided in the following
section, in which we describe a small pilot study.
Participants
Treatment
Results
Table 1
BES Scores. Scores on the BES decreased for all participants except
one. Three participants dropped from the ‘‘moderate problem’’ range
to the ‘‘little or no problem’’ range. Two participants dropped from
the ‘‘severe problem’’ range to the ‘‘moderate problem’’ range. One
participant’s score increased slightly (29 to 33). However, this partici-
pant reduced her objective binge episodes by 43%.
EDE Scales. Mixed results were obtained for the subscales of the
EDE. Restraint and shape concern scores improved slightly at post
treatment, while still well above the range of a normal control
sample. Scores on the weight concern scale increased slightly.
Ruth A. Baer, Sarah Fischer, and Debra B. Huss
EEI. Results were also mixed for scores on the EEI, which assesses
beliefs that eating is reinforcing in a variety of ways. Belief that
eating alleviates negative affect decreased, but was still above the
normal range of the validation study control sample. A decrease of
nearly one standard deviation was noted in the belief that eating
leads to feeling out of control, which is consistent with the decrease
in EDE eating concern scale scores. Finally, belief that eating allevi-
ates boredom increased slightly. This may be related to the increase
in subjective binges, in which participants labeled eating in response
to stimuli other than hunger as a binge. It is also possible that
increased mindfulness enabled participants to recognize more easily a
tendency to eat when bored.
BDI-II. For five participants, scores on the BDI-II fell to the minimal
range. The sixth participant showed an increase in her depression
score. This seemed related to several stressful personal circumstances
that arose during the course of treatment.
Discussion
states, rather than increased binge eating per se. Small increases in
weight concern at post-treatment also were noted. Although
therapists attempted to clarify that treatment was aimed at binge
reduction rather than weight loss, many participants were obese and
hoped to lose weight as a consequence of stopping binge eating.
These participants may have been even more concerned about their
weight when this did not occur.
GENERAL DISCUSSION
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