Clinical Handbook of Mindfulness (78 page)

hands on your stomach to help you notice whatever your body has to share

with you
. . .
if it is giving you any sensations of hunger
. . .
Remembering that

these may be very subtle, or they may be very intense and obvious
. . .
There

are no right or wrong sensations
. . .
just noticing whatever physical sensations

are taking place in your belly
. . .
your body
. . .
sensing what your body is telling

The Hunger/Fullness Scale

The goal is to eat when you feel 2 to 2.5 (moderately hungry),

and to stop eating at 5 to 5.5 (moderately full).

Very

Neutral

Very

Hungry

Full

1

2

3

4

5

6

7

Figure. 14.1.
Seven-point Hunger and Fullness Scale.

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Ruth Q. Wolever and Jennifer L. Best

you, or not telling you in this moment
. . .
Noticing to yourself right now how

hungry or full you are, with 1 being as hungry as possible, and 4 being neutral,

and 7 being as full as you could possibly be.. [leave enough time for everyone

to find a number]
. . .
Again remembering that these sensations may be very

subtle or strong
. . .
making your best estimate of your hunger or fullness level.

Any slight pangs from the stomach, mild hunger, at say a 3? Or slightly stronger

signals, of moderate hunger, perhaps a 2.5 or a 2? Or are you too hungry? Feel-

ing stronger discomfort, lower than a 2? Just taking a minute to notice what

your stomach is telling you. No one knows this information better than you

. . .
So, as you become more aware of your hunger or fullness level, just asking

yourself how you know this?
. . .
What experiences or sensations help you find

the number/level?

You may also notice other sensations, feelings, or thoughts
. . .
Just noticing

whatever you are experiencing. Not trying to change it, but just noticing it.

Trying to separate out the emotion or thought from the sensations of physical

hunger
. . .
Or perhaps you don’t have any particular sensations, feelings, or

thoughts. Just training yourself to reconnect with your body
. . .
whatever you

experience is fine
. . .
just notice it, whatever it is
. . .
And with the next breath, or one soon after, you can begin to re-orient yourself to the room. And open

your eyes.

Teaching participants to register fullness is similar. In the initial trainings,

however, they are given fullness suggestions rather than hunger suggestions.

For example:

Again remembering that these sensations may be very subtle or strong
. . .
mak-

ing your best estimate of your hunger or fullness level. How physically satisfied

are you feeling? Perhaps your stomach feels warm, moderately full – perhaps a

5.5. Or maybe it is earlier in the process
. . . . . .
perhaps sensing just the very first

hint of stretch
. . .
a 5 or so. Or maybe it feels more stretch or a little distension,

if you have eaten more than you needed – say a 6 or so. Whatever physical

sensations you experience, just notice them. Also, noticing your emotions, and

thoughts. And being aware of the difference between physically and emotion-

ally satisfied. Perhaps you are bored, and want to get out of here. Or maybe you

are surprised to learn something about yourself. Whatever you experience, just

observe it, trying not to judge or criticize it.

Exercises in registering satiety are more easily accomplished in tandem

with the intake of a moderate meal, particularly one of high fiber. Participants

often say that they do not know what moderate fullness feels like; “I know

when I’m hungry and when I’m stuffed, but I never paid attention to the

in-between states.” It’s useful to remember that regaining this skill requires

attention, patience, and practice. Clinically, most can identify episodes when

they felt stuffed, and often report sedation at the same time. It is impor-

tant for them to eventually uncouple the cognitive label “full” and sensations

indicative of overeating. Some say they experience pain and others report

deep comfort at this state. Either way, the experience of over-fullness serves

to shift attention from thoughts or emotions to a set of sensations, and allows

a continued mislabeling of experience.

Participants benefit from carefully listening to others’ descriptions of

hunger-fullness ratings, particularly noting the physical sensations that led

them to choose that rating. Multiple examples are essential to learning

this process. This is also an ideal time to point out potential confounds if

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277

participants mention emotions rather than physical signals (e.g. irritable,

panicky, comfortable, happy), pointing out that physical rather than emo-

tional signals are the most reliable indicators of when to eat. While physiol-

ogy can sometimes lead to these (e.g. low blood sugar can make one irrita-

ble), there is a risk in using these to signal a need to eat since other things

can also create such emotional states.

It is also not uncommon for participants with significant dieting and/or

bingeing histories to say, “I feel nothing” when first asked to register hunger

or fullness signals. It can take weeks of practice, particularly preceding, dur-

ing and following meals; individuals that have been disconnected from their

somatic experience for years need continual encouragement and practice to

begin to register these cues again. In clinical practice, very few individuals

have been unable to re-learn to sense these cues; these failures may have

been due to complications of diabetes such as neuropathy.

Skill Set 6: Recognition of taste
– Geneen Roth’s early clinical work

(e.g.,
Roth, 1984)
also centered attention on taste; again, MB-EAT and

EMPOWER expand this to add components of nonjudgment. A segment of

such an exercise using chocolate reads:

Begin by placing a single Hershey’s kiss in front of you, out of your hands.

Allow your eyes to close or find a downward gaze if closing your eyes feels

too uncomfortable. Just resting your hands on your stomach, and inviting 4–5

deep, easy breaths. Not forcing the breath, but just inviting it all the way to the

bottom of the lungs. You may feel your chest rise and fall. You may feel your

ribs expand out to the sides and release. And as the breath gently reaches the

bottom of your lungs, you may feel your abdomen expand on the inbreath, and

contract on the outbreath. So just allowing the body to rest while you move

your attention to the stomach and mouth. Just noticing what physical sensa-

tions you have at this time. Noticing any thoughts you have
. . .
any emotions.

And being aware of the difference between physical sensations on the one hand

and thoughts or emotions on the other. Whatever you experience, just observe

it, trying not to judge or criticize it. Just noticing whatever you are experienc-

ing. Not trying to change it, just noticing it. Or perhaps you don’t sense any

particular sensations, feelings, or thoughts. That’s OK too. At this point, just

notice it, whatever it is.

In the next breath, or the one after that, just allowing your eyes to fully open

but maintain a downward gaze, Taking the piece of chocolate in your hand,

just unwrap it gently. Continuing to be aware of any thoughts or emotions that

pass through your mind. Now just looking at the chocolate, holding it in your

flat hand, noticing it as if this were the first time you had ever seen chocolate.

If you were a painter, how would you paint it? Noticing the shape, the size, the

colors, the way the light reflects on it
. . .
(long pause)

Now moving your attention to the smell of the chocolate. Placing it under

your nose and closing your eyes again
. . .
just noticing the scent. Where in

your nose do you smell the chocolate? What aspects of it can you smell? Milk?

Vanilla? Tobacco or an earthy scent? Just noticing all you can about the scent

. . .
(long pause)

Now rubbing the kiss on your lips so you get just a hint of flavor. Allowing

your eyes to remain closed
. . .
What do you taste? What do you notice about

the texture? Is it smooth or gritty? Melting or not? Just being aware of all the

intricacies in this one chocolate kiss.

Now placing the chocolate on your tongue, and just holding it in your

mouth, not biting it. What do you now notice about the flavor? Move it around

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Ruth Q. Wolever and Jennifer L. Best

your mouth. Does it taste different in different parts of your mouth? Allow it

to melt on your tongue. What do you notice as it melts? Just allowing yourself

to be fully present with this bite. What do you notice about your saliva? About

your mouth itself? Does the flavor change over time, as it melts? In what way?

Just taking as long as you like to allow the chocolate to melt and to fully expe-

rience the sensations of eating it. Can you feel it move out of your mouth, into

your throat? Down your throat toward your stomach? And being aware of any

thoughts or emotions that pass through, distinguishing a thought or emotion

from a sensation like taste
. . .
What if you ate like this most of the time?
. . .

Observing whatever is present for you now, without judging it
. . .
(very long

pause)
. . .
and opening your eyes when ready.

Skill Set 7: Discernment of appetite regulation cues from other

internal events
– Appetite regulation cues (hunger, fullness and taste-

satiety) need to be teased apart from emotions, thoughts, behavioral urges

as well as other physical sensations (e.g., fatigue) in order to be well utilized.

While learning this skill set requires the acquisition of the previous six skills,

the learning is not a linear process. As such, the EMPOWER program lay-

ers skill training in each of these arenas. Each skill influences the other, and

new contexts challenge existing skills. For example, once participants can

sense an emotion, and can sense hunger, they can begin to compare them

and develop personal ways to distinguish between the two. Refining that dis-

tinction further informs the identification of emotion and hunger, and so on.

One female participant, for example, over time noted that her anxiety sensa-

tions are higher in the chest while hunger signals emanate from the stomach

area right below the breastbone. Another participant who often ate to quell

anxiety observed that she is most aware of sensations of anxiety (e.g., pal-

pitations) at the bottom of the breath, after the exhale when she can feel

her heartbeat most saliently. These powerful realizations gave these women

mechanisms to use in distinguishing anxiety and hunger.

Skill Set 8: Identification of true needs
– Once participants are profi-

cient in observing and teasing out the components of their own experience,

the EMPOWER approach encourages the next step; to make an informed

decision to best address their true needs. Although reactivity is sometimes

driven by habit alone, it often is an attempt to meet an underlying need. As

participants gain skills in nonjudgmental self-observation, they are able to

discern their true needs with greater clarity. For example, if the true need

is boredom, participants may decide to find a better way to entertain them-

selves. If the true need is temporary fatigue, sleep may be a useful response.

If the true need is frustration related to a specific incident, assertiveness or

problem solving may be appropriate. In theory, once the true need is iden-

tified, wise mind then guides behavior choices. Many participants, however,

also appear to benefit from having specific exercises to clarify their processes

for decision making.

Skill Set 9: Addressing true needs
– Clinical scientists have underscored

the need to promote greater self-acceptance in individuals with ED while

still fostering meaningful behavioral change (e.g.,
Wilson, 1996).
EMPOWER

participants appear better able to deal with this dialectic when needed

changes are contextualized as attempts toward enacting their personal mis-

sion statements and visions for health. They are guided to reflect on and

develop personal mission statements (similar to ACT approaches), as well

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

279

as to spend time cultivating a long-term vision for health. Participants then

use this context of what they really want for themselves in the long run to

guide decisions in the moment. Stop-Breath-Connect is taught to encourage

participants to take a momentary pause before behaviors they are trying to