Clinical Handbook of Mindfulness (76 page)

phases: (1) theoretical rationale of the program, (2) teaching principal com-

ponents of DBT and (3) reinforcing and generalizing gains
(Telch, 1997).
This approach yielded significant improvements in binge eating though weight

and mood symptoms did not stabilize
(Telch
,
1997).
Telch and collaborators then tested the efficacy of the approach in a group DBT program for BED in

an initial uncontrolled trial
(Telch, Agras, & Linehan, 2000);
eighty-two percent of the sample attained binge-free status by the end of the 18-session pro-

gram
(Telch et al., 2000;
see
Wiser & Telch
,
1999
for a detailed description of the intervention) and abstinence rates remained high three (i.e., 80%) and

six months (i.e., 70%) post-treatment.
(Telch et al., 2000).
Eating, weight and shape concerns also improved, as did self-reported emotional eating urges

and negative mood regulation
(Telch et al., 2000).

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

269

In a more rigorous RCT
(Telch, Agras, & Linehan, 2001),
44 women with BED reduced objective binge eating behaviors in both a DBT and wait-list

control condition
(Telch, Agras, & Linehan, 2001).
However, among the 18

that completed treatment, those in DBT showed significantly higher absti-

nence rates by the end of treatment relative to controls (i.e., 89% versus

12.5%), though sustained improvements were more modest (i.e., 56% absti-

nent at 6-month follow-up). DBT-completers were also characterized by less

weight, shape and eating concerns and on average reported a weaker urge to

eat in response to anger than wait-list participants
(Telch, Agras, & Linehan,

2001).
Subsequent post-hoc analysis of women who completed DBT across

both trials (N = 32) indicated that early onset of binge eating (prior to age

16) and higher restraint scores at baseline predicted poorer outcome (Safer,

Lively, Telch, & Agras,
2002).

The application of DBT to treating BN and AN is less well-developed.

Safer et al. (2001a)
provided the first clinical account of adapting DBT for treatment-resistant BN with positive results
(Safer et al., 2001a).
In addition, one RCT of women with BN showed greater reductions in binge eating and

purging for DBT participants compared to wait-list controls (Safer, Telch, &

Agras,
2001b).
Regarding AN,
McCabe and Marcus (2002)
discuss the effectiveness of DBT from a clinical standpoint, though virtually no research has

empirically tested whether DBT is useful for treating AN. The one exception

is a current uncontrolled pilot study being conducted in Germany of inpa-

tient adolescents with AN and BN
(Salbach et al., 2007).

Three directions for future DBT research with ED would supplement the

promising findings thus far: (1) testing the manualized, integrative approach

against or as a complement to traditional CBT, Interpersonal Therapy (IPT)

and family-based interventions; (2) testing DBT for AN; and (3) exploring

the generalizability of the findings by including males and ethnically diverse

samples.

Acceptance and Commitment Therapy (ACT)

The second mindfulness-based approach that can be easily adapted for ED

is ACT
(Hayes et al., 1999).
Conceptualized for treating a wide range of psychiatric and behavioral disorders, its core philosophy holds that maladap-

tive behaviors are purposefully or habitually performed to reduce or control

aversive experience (e.g., self-critical cognitions, negative emotions, painful

bodily sensations;
Hayes et al., 1999).
Ongoing distress and dysfunction are maintained by this experiential avoidance as well as by cognitive fusion (i.e.,

holding thoughts to the level of absolute truths such as “I think I’m fat; there-

fore I am”). The adaptation of ACT as a treatment for ED is theoretically

appropriate given its excellent fit with the prominent models explaining eat-

ing pathology (restraint, emotion regulation, and escape theories).

ACT utilizes mindfulness skills, metaphor, and cognitive defusion tech-

niques to reduce cognitive-behavioral rigidity, improve self-regulation and

overall quality of life
(Hayes et al., 1999).
ACT further emphasizes clarification of important life values as a continuous form of motivation for

sustaining adaptive behavior change
(Hayes et al., 1999).
In essence ACT

exposes patients to the very aspects of their experience they deem prob-

lematic, but from a de-centered, mindful and accepting vantage point. This

270

Ruth Q. Wolever and Jennifer L. Best

exposure-based component along with values clarification assists patient

in more creatively engaging in and adapting to a wide range of life

circumstances.

Although ACT has received noteworthy support for improving symptoms

across a spectrum of clinical disorders
(Hayes, Luoma, Bond, Masuda, & Lillis,

2006),
there is a dearth of such work conducted in eating disordered samples. The existing literature is comprised of single case studies in AN (Bow-

ers,
2002;
Hayes & Pankey, 2002; Heffner, Sperry, Eifert, & Detweiler, 2002;

Orsillo & Batten, 2002).
Wilson and Roberts (2002)
provide an important overview of issues to consider in assessing and treating AN from an ACT

perspective. Clearly, clinical trials of ACT-based approaches for improving

core eating pathology symptoms are one promising area of further scientific

inquiry.

Mindfulness-Based Cognitive Therapy (MBCT)

MBCT is an extension of Jon Kabat-Zinn’s pioneering Mindfulness-Based

Stress Reduction (MBSR;
Kabat-Zinn, 1990)
program aimed at the endur-

ing cognitive vulnerability in chronic, treatment-resistant depression (Segal

et al.,
2002).
MBCT applies core mindfulness skills from MBSR (e.g., body scan meditation, sitting meditation, walking meditation, awareness of the

breath, mindful yoga) to reduce the believability of persistent depressogenic

thoughts and to improve the pervasive affect avoidance style
(Segal et al.,

2002).
However, in contrast to existing cognitive therapeutic change techniques, MBCT, much like ACT, does not attempt to change the
content
of

experience; rather, it challenges the individual to alter the
context
of expe-

rience through practicing acceptance and “letting be”
(Segal et al., 2002).

Baer and collaborators evaluated MBCT for treating binge eating in subclin-

ical and clinical BED
(Baer, Fischer, & Huss, 2005; Baer et al., 2006).
They used MBCT to reduce reactivity toward automatic thoughts and emotions

that precede binge eating rather than reducing the thoughts and emotions

themselves. Unlike other mindfulness-based approaches to eating disorders,

(e.g., MB-EAT, DBT and ACT), there is a stronger emphasis placed on training

in pure mindfulness strategies in the absence of directly applying mindful-

ness to eating, physical activity, or CBT approaches such as problem-solving

or assertiveness skills
(Baer et al., 2005).

In the original case analysis, MBCT was associated not only with both

immediate and sustained improvements in binge eating pathology but it also

led to significant increases in self-reported mindfulness
(Baer et al., 2005).

Similarly, a more recent uncontrolled trial of a 10-session MBCT showed posi-

tive effects for objective binge eating, self-reported binge eating severity, and

eating concerns
(Baer et al., 2006).
Women in this trial also demonstrated notable increases in self-observation and nonjudgment of these private

events following treatment
(Baer et al., 2006).
These preliminary findings are encouraging, and set the stage for RCT evaluation of this approach.

Mindfulness-Based Eating Awareness Training (MB-EAT)

Also informed by MBSR, the first mindfulness-based approach created specif-

ically for treating an eating disorder
(Kristeller & Hallett, 1999)
applied mindfulness to CBT and guided imagery developed to address weight, shape

and eating-related self-regulatory processes. The approach, later named

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

271

MB-EAT
(Kristeller et al., 2006)
is consistent with affect regulation models (e.g.,
Wilson, 1984),
restraint theory (e.g., chronic dieting model of Herman & Polivy,
1980),
the escape model
(Heatherton & Baumeister, 1991)

and mental control
(Wegner, 1994)
yet further expands these self-regulation explanations to include the science of food intake regulation including the

role of hunger and satiety cues. Using a single group pre–post, extended

baseline design,
Kristeller and Hallett (1999)
demonstrated reductions in self-reported symptoms of binge eating, binge severity, anxiety and depression in

obese women with BED undergoing a six-week treatment. Importantly, cor-

relational analyses indicated improvements in binge eating were associated

with improvements in mindfulness, eating control and awareness of satiety

signals Moreover, time spent practicing eating-related meditations predicted

lower binge severity
(Kristeller & Hallett, 1999).
The original approach was then expanded to a 9-session treatment (MB-EAT: Kristeller, Baer, & Quillian-Wolever,
2006; Kristeller, Wolever & Sheets, 2008),
informed by Craighead’s appetite awareness training
(Craighead & Allen, 1995;
Allen & Craighead,

1999)
and deeper levels of self-acceptance work using forgiveness and cultivation of inner wisdom for sustaining change. The efficacy of MB-EAT

was then tested in a dual site RCT comparing it to an active CBT-informed

psychoeducational approach, and a wait-list control (Kristeller, Wolever &

Sheets,
2008)
in an ethnically diverse sample of obese men and women

with BED or subclinical binge eating patterns. Intent-to-treat analyses showed

declines in objective binge eating, binge eating severity and depressive symp-

toms for both active treatments. However, only those randomly assigned to

the MB-EAT condition exhibited lower levels of food locus of control, suggest-

ing a greater internalization of change
(Kristeller, Wolever & Sheets, 2008).

Interestingly, significant improvements in post-prandial glucose metabolism

(Wolever, Best, Sheets, et al., 2006; Wolever, Best, Sheets, & Kristeller,

2008)
were also found solely in the MB-EAT group, and independent of

weight change. This finding raises the possibility that the mindfulness-based

approach also influences biological indices of self-regulation in a way that

other behavioral approaches do not. The U.S. National Institutes of Health

are currently funding additional testing of this hypothesis in conjunction

with efficacy trials of this approach for weight loss (MB-EAT; NIH Grant

5U01 AT002550) and weight loss maintenance (EMPOWER: NIH Grants 5U01

AT004159 and 5 U01 AT004158). These grants have allowed the opportunity

to further enhance and develop this approach, resulting in the current 15-

week protocol (described below) called EMPOWER (Enhancing Mindfulness

for the Prevention of Weight Regain;
Wolever et al., 2007).

One additional approach merits mention. Preliminary findings from a non-

clinical sample of community participants with binge eating tendencies sug-

gest utility in an 8 week modified MBSR approach with psychoeducational

components
(Smith, Shelley, Leahigh, & Vanleit, 2006).
Randomized, controlled testing of this model is certainly in order.

EMPOWER Exercises and Participant Experiences

Training in traditional mindfulness techniques (e.g., sitting meditation, body

scan) provides a basic platform from which to nonjudgmentally learn about

oneself. In addition, this learning platform appears to facilitate application

272

Ruth Q. Wolever and Jennifer L. Best

of CBT and other traditional skills known to enhance recovery. In the

EMPOWER approach
(Wolever et al., 2007),
there are at least 9 core skill sets, all of which are fundamental to recovery from eating disorders:

1. to nonjudgmentally observe the bundle of reactive thoughts, emotions

and body sensations that drive behavior;

2. to separate emotions from this bundle of reactivity;

a. that emotions are transient events that often do not require response;

3. to separate thoughts from this bundle of reactivity;

a. that thoughts are just thoughts, transient events that often do not

require response;

4. to separate and tolerate behavioral urges from this bundle of reactivity;

5. to clarify physiological signals of hunger and fullness (gastric satiety);

6. to attend to taste-specific satiety;

7. to discern the physiological signature of appetite regulation cues (5 and 6)

from emotions (e.g., the difference in anxiety and hunger; the difference

in peaceful and stuffed);

8. to discern the true need underlying the reactivity; and