Insight Meditation on the Treatment of Disordered Eating - Article Example

Insight Meditation on the Treatment of Disordered Eating It’s well-known that 40 percent or more of women with disordered eating do not improve using current therapies such as medications, psychotherapy, and cognitive behavioral therapy (CBT), and the long-term prognosis for such patients is not good (Cook-Cottone, Beck and Kane 2008; Baer, Fischer and Huss 2005; Corstorphine 2006). There is wide-ranging speculation on which therapeutic component is missing or missed by this group, and therapists will often try alternate forms of treatment when something fails (Smith et al. 2008). Perhaps these treatments fail for a great number of women because the oftentimes fine and undulating emotional component of the patient’s experience is not being sufficiently addressed in these therapies to balance the emphasis on changing behaviors and reshaping reactions. For those with disordered eating, learning healthy ways to experience and express emotions can be a key turning point in understanding perceptions as they actually are, rather than what patients think they are (Baer, Fischer and Huss 2005; Corstorphine 2006). Experiencing and expressing emotions in healthy ways are learned skills. Interventions like experiential work, dialectical behavior therapy, cognitive behavioral therapy, and especially mindfulness training help the patient to objectively identify subjective emotions (Kristeller 2003; Baer, Fischer and Huss 2005; Wolever and Best 2009; Smith et al. 2008; Corstorphine 2006), in the identification distance themselves from emotional states in order to address rather than escape, block or change them. Then, the patient has the freedom to reorder her experiences and emotions into healthy patterns. Emotional states play a large part in how we view ourselves and the world (Corstorphine 2006). The perceptions of the five senses are reordered from empirical facts into something entirely different once they reach our brains, and past experiences, subconscious and conscious memories, and feelings then reorder those perceptions again into external behaviors and what we think we understand. What we actually “see” about the world is not necessarily what we “get.” Mindfulness training, while far from a new or innovative approach, is just starting to become an accepted treatment for eating disorders in the mainstream West (Chambers, Lo and Allen 2008; Dryden and Still 2006; Martin 1997; Smith et al. 2008). The training teaches meditation and relaxation techniques, certainly, but it goes much deeper than that to the actual self-awareness of the patient and teaches her how to accept herself current state of being with compassion (Kristeller 2003; Smith et al. 2008; Corstorphine 2006). Emotional states do not control behavior, nor does the patient control emotional states; she simply learns how to experience and express what she feels as a part of moment by moment awareness. While mindfulness proponents have steered clear of Buddhist or religious overtones in the training (Martin 1997; Smith et al. 2008), the most effective way to practice living in the present moment is to explore the skill through mindfulness meditation: the practice of noticing and embodying the movement of breath, bringing awareness into body. Meditation is not simply a relaxation technique; in fact, when practiced regularly and with focused attention, meditation can be actively applied to various areas of everyday living (Smith et al. 2008). The practice allows the mind to be still enough so it opens to the discovery of the present experience, with compassion and without judgment. This can provide a balanced transformational experience in being with the emotions of a patient with disordered eating. Emotional States It is common knowledge that there is a solid link between emotions and eating disorders (Baer, Fischer and Huss 2005; Corstorphine 2006). Emotions are at work within humans at all times, and both trigger and result from disordered eating episodes such as binge eating or anorexia. The “blocking model” and the “escape from awareness” model (Corstorphine 2006, p. 450) describe in clinical terms what eating disorder sufferers report about their emotions. A person blocking her emotional states uses irregular eating behaviors to avoid feeling negative (or even positive) primary and secondary emotions. The escape from awareness model, usually associated with binge eating, suggests that distress is escaped by binging; thus its full effects are not felt. Patients with disordered eating pathologies self-report and are observed to have inaccurate beliefs about emotional states and their consequences (Martin 1997; Chambers, Lo and Allen 2007; Smith et al. 2008; Corstorphine 2006). Emotions, whether expressed or suppressed, have consequences and rewards. Suppressing emotions rewards the individual by leading her to believe that she is in control, at least for a short time. She may feel safe because she is not taking the risk of expressing her emotions, or believes that because what she is feeling is wrong somehow, so not expressing emotions will allow her to be right Corstorphine 2006). These are rewards, even if they are not healthy rewards. Over the long term, unexpressed emotions cause the patient to lose control of behaviors; blocking or escaping stops working and the symptoms of an eating disorder emerge. Emotion regulation (not control) is important for the person suffering from disordered eating to achieve (Cook-Cottone, Beck and Kane 2008; Baer, Fischer and Huss 2005; Corstorphine 2006). When there is plenty of food around, we tend to eat based on emotions or habits rather than the actual physical feeling of hunger, leading to obesity or eating disorders. Childhood habits and current social pressures guide our food choices, not the feeling of hunger or the need for nutrition (Kristeller 2003; Baer, Fischer and Huss 2005). When a person is disconnected from both emotions and physical signals, an eating disorder may result. The intense desire for a thin body, coupled with a distorted view of the body and unregulated emotional states, drives the sufferer into circular ruminations about food and a poor self-concept. If the emotional, cognitive and psychological problems persist, extreme weight loss or the binge-purge cycle actually does disconnect the body from the brain. Eating disorders help the sufferer to escape negative emotions. A limited range of emotional regulators leads the person to manage stress, pain and negativity through binge eating or severely restrictive diet (Baer, Fischer and Huss 2005; Wolever and Best 2009; Corstorphine 2006; Smith et al. 2008). For the binge eater, small stressors become overwhelming. Excessive consumption relieves the stress temporarily. Later, purging the excess food relieves the stress and guilt of overeating. Distress is handled by adding more distress to the situation. The restrictive anorexic, on the other hand, handles her fear and self-loathing by avoiding food altogether, thus avoiding the emotional states and thoughts that cause her distorted self-image. Unpleasant moods and uncomfortable emotions interfere with problem solving. Those feelings don’t go away; they re-emerge in compulsive or impulsive behaviors and the disordered eating sufferer grows more confused, angry, shameful and guilty the more the cycle is repeated (Martin 1997; Chambers, Lo and Allen 2005). Mindfulness insight meditation takes the first steps in becoming aware of moods and emotions so the practitioner can move on to problem solving without being caught up in unhealthy rationalization—or complete lack of rationalization, which leads to loss of control. Problem solving cannot be forced upon a disordered mind. Mindfulness insight meditation and related mindfulness techniques turn the patient’s attention inward in a healthy, compassionate, and accepting way. When applied to the behavior of eating, these techniques “allow individuals to tease apart physiological cues of emotion [from] those of hunger or satiety” (Wolever and Best 2009, p. 264). Rigid patterns relax, distorted thinking re-orders itself, and a realistic assessment of the person’s appearance can emerge (Baer, Fischer and Huss 2005; Smith et al. 2008; Corstorphine 2006). The Roots of Mindfulness No matter what name it goes by, mind-body stress reduction, mindfulness, meditation, etc. is adapted from Buddhist precepts which have been practiced for thousands of years (Kristeller 2003; Dryden and Still 2005). Pure Buddhism recommends adhering to a “middle way” rather than seeking extreme pleasure or allowing extreme pain. Balance and acceptance are key precepts. Vipassana, the Sanskrit word for mindfulness, aims to focus the attention on one stimulus at a time in a sustained manner, and develops the ability to change attentional focus at will (intentionally) (Martin1997). Breath work is the first step for the novice to meditation: concentrate on natural breathing and nothing else for ten minutes to half an hour; allow thoughts and emotions to enter and leave the mind without trying to keep them there or make them leave; bring the attention back to the breath over and over until there is nothing else in the world. Then, take that skill out into everyday life and focus intentionally on every aspect of life in each present moment. Jon Kabat-Zinn brought meditation to the forefront of psychology and medicine when he began studying it as a method for pain reduction in cancer patients in the early 1980s. He defined mindfulness as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn 1994, p. 4, quoted by Dryden and Still 2006, p. 5). Because of his carefully controlled and replicable studies with chronic pain sufferers, Kabat-Zinn showed that mind-body stress reduction was indeed evidence-based practice, bringing the ancient tenets of Buddhist meditation to the mainstream modern medicine. Kabat-Zinn effectively secularized an ancient spiritual tradition. Kabat-Zinn’s “raisin” exercise (discussed in Kristeller 2003) sets a potential meditator off on the purposeful journey through a seemingly simple exercise: eat on raisin as completely and mindfully as possible. Focusing the attention on a single piece of dried fruit might seem strange, but there is, of course, more to the activity. Eating a raisin involves the taste buds and physical act of chewing and swallowing. Perhaps it also involves a childhood memory or strong feelings of pleasure or discomfort, not necessarily associated with the bit of dried fruit. When thoughts beyond the basic five-senses-perceptions enter the mind, they are allowed to come and go while the mindful mind remains compassionate and observing. With enough practice, there is distraction from the experience of eating a raisin. Mindfulness is the ultimate goal, but exploring every nook and cranny of the experience is the skill being taught. To put it another way, “While insight is a possible outcome of psychodynamic work, so is self-acceptance or compassion” (Martin 1997, p. 303). Intentionality lies at the base of mindfulness and meditation. This simply means that a person does what she does on purpose, with intention, not only during the quiet of meditation practice but hopefully in every moment. Meditation teaches a person to recognize thoughts and emotions and let them pass without judgment, or to examine them very closely if need be without other thoughts or emotions interfering with the examination (Martin 1997; Baer, Fischer and Huss 2005; Dryden and Still 2006). With enough practice, this intentionality can be practiced outside the confines of the meditation pillow. Patients with disordered eating often lack self-awareness and impulse control, and are disconnected from their emotional states and bodies (Proulx 2008). By learning the skill of intentionality, self-awareness improves, behaviors are less impulsive, and the practitioner can reconnect with emotions without fear of the risks and consequences. One goal of pure meditation is to integrate all dualities, particularly the mind-body duality, into oneness. Eating disordered patients often report they feel they have dual selves: the first is the eating disordered self, and the second is the person she pretends to be to the outside world (Cook-Cottone, Beck and Kane 2008; Dryden and Still 2005). By learning the skills to practice mindfulness, paying attention to the present moment, and developing an attitude of open acceptance to all experiences (Smith et al. 2008; Chambers, Lo and Allen 2007; Martin 1997), those who suffer from disordered eating begin to integrate these two selves or to abandon them altogether. It can feel like a wildly swinging pendulum, but “Meditation practice may provide a way to bring this pendulum back into balance, to allow for living in the present, without either overly grasping or rejecting” (Kristeller 2003, p. 9). Attentional focus, once learned, allows the person to acknowledge experiences and emotions, watch them as long as they remain, examine them without judgment, and let them go without rejection (Martin 1997). Kabat-Zinn’s continuing work in the study of mindfulness insight meditation shows therapists that it is eminently teachable to a wide range of subjects, both the sophisticated and unsophisticated, the impressionable and the therapy-resistant. Mindfulness in Kabat-Zinn’s sense closely parallels that of ancient Buddhist practice which takes the practice off the pillow and applies it to every moment. Focused attention and intention become a state of mind, allowing people suffering from a wide range of ailments to heal. It is not Buddhism, and MBSR picks and chooses techniques and re-forms meditation practice to be useful for the purpose of stress reduction. Cognitive-Emotional-Behavioral Therapy (CEBT) Although it is a struggle, addicts can quit smoking, drugs or alcohol and remain free from the addiction through abstinence while working on the emotional and cognitive disruptions that led to the addictive behavior. It is not possible to abstain from food; we need it to survive. This complicates recovery from disordered eating. The patient must learn moderation and flexibility, compassion and acceptance, or she will fall back into the same traps that brought her to the dysfunctional behavior. CEBT begins by helping the patient to identify past experiences or environments which have led her to develop unhealthy patterns of experiencing and expressing emotions. In one example (Corstorphine, 2006), childhood experiences led a patient to believe that expressing emotions made her unlikeable, so she internalized the feelings out of guilt and shame (453). The emotions kept working subconsciously, and found their way out through bingeing and purging episodes (up to five times per week). Through cognitive-behavioral therapy, this patient learned to modify her behaviors, but was still bingeing and purging three times a week. After adding the emotional component through diary work, she was more able to identify triggers and beliefs, and adapt her responses to healthier patterns. Cognitive-based therapies tend to focus on the distorted thoughts of the eating disordered patient (Baer, Fischer and Huss 2005; Chambers, Lo and Allen 2007; Corstorphine 2006). She views herself as overweight by comparison to an ideal, and feels that normal stresses such as not being completely accepted by a group or what others would consider a normal lack of self confidence could be fixed if only she had the right body shape. This leads the disordered eating patient to invent dietary rules, which then leads her to violate those rules because her body demands nutrition or her emotions are disordered. Thought processes lead to more thought processes in an unhealthy loop of rumination. The CBT therapist attempts to help the patient break through these unhealthy loops, understand their basis, and reform thoughts into more acceptable patterns (Baer, Fischer, and Huss 2005; Corstorphine 2006; Dryden and Still 2005; Chambers, Lo and Allen 2007). CBT and CEBT are useful for patients and well-understood by the traditionally-trained therapist, psychologist, or psychiatrist. Some forms of these therapies have been practiced to approach maladaptive behavior and emotional disturbance for many decades. CEBT has also been studied in clinical settings, lending credence to the idea that it can be an effective way of modifying behavior and understanding emotional states (Chambers, Lo and Allen 2007; Corstorphine 2006). Another layer of cognitive-emotional behavioral therapy combines CEBT with mindfulness insight meditation to produce mindfulness-based cognitive therapy (MBCT). It seems the more skills people are taught, the more able they are to make it through an episode of their illness (Chambers, Lo and Allen 2007; Dryden and Still 2005). Repeated meditation practice breaks down habitual and unhealthy patterns of response and allows the subconscious behavior to become conscious, while cognitive skills trigger the conscious mind to intentionally deal with the problem. Martin (1997) points out that psychotherapists and patients employ many of the tenets of mindfulness as a natural part of the therapeutic process (292). Without naming it as such, the fundamental tenets of mindfulness are at work between therapist, patient, and group therapy members: empathy, acceptance, gentle guidance, attention, intention, and integration. Even a process as simple as free association (letting thoughts and feelings connect with each other no matter how silly or upsetting they might be, in a flow of images and words) is similar to open form mindfulness insight meditation (Martin 1997). Cognitive-behavioral therapy is a prime example of using these components together to bring about a healthier world-view. However, the task oriented nature of CBT and related therapies sets them apart from mindfulness insight meditation in its basic form (Martin 1997; Chambers, Lo and Allen 2007). Empirical Studies Cook-Cottone, Beck and Kane (2008) comment that it is difficult to complete empirical studies on almost any therapy for disordered eating because sample sizes are often small, attrition rates are high, and randomized, controlled studies are nearly impossible because symptoms vary from individual to individual (61). These problems plague the study of nearly any psychotherapy or behavioral treatment. Researchers often use the participants’ own words when discussing the effectiveness of the study. This does not discount the conclusions, only directs those who follow to read the studies with that fact in mind. Proulx (2008) reports that six college-age women with entrenched symptoms of bulimia nervosa, who were currently participating in psychotherapy, participated in a treatment group with eight weeks of intensive meditation training. Two hours of guided meditation, psychoeducation, and discussion was followed by homework: guided meditation CDs for 10-30 minute individual daily sessions, and seven small meals eaten with intention each day, among several other tasks. Before participating in the group therapy, the women reported extremes in their thoughts, feelings and behaviors, and extreme disconnection from their inner selves and their actual, exterior selves. At the conclusion of the study, each woman reported she was moving from her previous behavior toward a more integrated self image and a healthier way to handle emotional states which formerly caused bingeing and purging behavior. It would be interesting to see a follow up study five years later to see if the women continued to use mindfulness and intentionality to approach their unhealthy behaviors. Smith, Shelley, Dalen, Wiggins, Tooley and Bernard (2008) conducted a pilot study which involved 50 participants. Thirty-six self-selected to participate in an eight week meditation, gentle yoga, and body scanning exercise course (mindfulness-based stress reduction, or MBSR). Fourteen participated in an eight week cognitive-behavioral techniques course (cognitive-behavioral stress reduction, or CBSR). When exit outcomes were compared for the two groups, those participating in the MBSR course of study showed statistically significant improvement over those in the CBSR coursework, although all subjects reported improvements. Chambers, Lo and Allen (2007) studied the process of mindfulness training and its effects on 20 subjects and a similar control group who did not receive training. Novice meditators participated in a ten-day intensive retreat. Subjects performed up to 110 hours of actual practice, adhered to strict codes of discipline while at the retreat, and did not communicate with the outside world or participate in any kind of entertainment. Only mindful insight meditation was taught and practiced; no relaxation techniques, yoga, or other cognitive therapies entered in. The retreat was also conducted at a meditation center in Victoria, Australia. At the conclusion of the study, subjects who participated in the training reported enhanced levels of mindfulness, reduced levels of depressive symptoms and reflective rumination (negative circular thought patterns) and some improvement in cognitive functions. Interestingly, participants’ working memory function improved significantly. Kristeller (2003) intensively trained a group of chronically obese binge eating patients using guided mindfulness meditation over an eight-week program. At the conclusion, subjects who learned mindfulness insight meditation reported they felt a powerful connection with other members of their group, unlike those who participated in a similar study but were taught cognitive-behavioral strategies. For most of them, this powerful connection also translated to a more powerful connection with food—in a positive sense. Studies involving randomized subjects are difficult, as mentioned earlier (Cook-Cottone, Beck and Kane 2008). Unlike testing the efficacy of pharmaceuticals, therapeutic treatments are inherently dependent on the subjects’ or the researchers’ biases, which can be controlled for somewhat but not completely. The MAAS (mindful attention awareness scale) measure taps into levels of mindful awareness in the subject (or therapist) and separates mindfulness from other psychological characteristics (Chambers, Lo and Allen 2007; Smith et al. 2008). This scale is useful but again, it must be remembered the results are self-reported. Mindfulness insight meditation is on the frontier of psychology (as a therapeutic treatment), and it will probably be many years and many studies before there is enough study to equal that of cognitive-behavioral therapies, individual or group counseling, or psychotherapy. It is often difficult for people with eating disorders to recognize and respond to internal cues in a healthy manner, whether those cues are hunger pangs or emotional states. Mindfulness insight meditation teaches people to recognize cues for what they are, rather than what the person thinks they are or wishes they would be (Martin 1997). Truly randomized studies would ask participants to observe their internal states without teaching them the skills necessary to interpret those observations (Cook-Cottone, Beck and Kane 2008). Insight Meditation and Disordered Eating Empirical studies are an excellent way to test the efficacy of theoretical frameworks. The small number of participants and the self-reported nature of both their emotional states and their healing processes is an unavoidable difficulty in studying most kinds of psychological therapies. While some patient symptoms are physiological, some are cognitive or emotional, and each person is an individual. Therapists must navigate an overwhelming number of theories which are only slightly different from one another (CBT, CEBT, MSRT, MBSR, CBSR, MBCT, etc.). Mindfulness is practiced in each one of these therapies, either overtly or as a natural part of the human interaction. Restructuring reactions to the world around us is not an easy task, and a number of therapies can be tried to help the patient restructure their thinking (Baer, Fischer and Huss 2005; Chambers, Lo and Allen 2007; Corstorphine 2006). A therapist can help a patient begin the journey of self-discovery, and even accompany her part of the way, but ultimately she must learn sufficient skills to restructure and reorder her world outside the guiding influence of the therapist’s (or therapeutic theory’s) reach. Mindfulness training provides a simple skill-set for the patient to apply to each and every moment of life, not just those moments controlled by the eating disorder. Food should provide a satisfying emotional experience. The chemical and physical processes of eating, digesting, and utilizing nutrients act on every system of our bodies, including the emotion centers of the brain. We are programmed to take pleasure in eating and in the process of procuring and cooking food. Structure and habit are necessary components. When a person suffers from disordered eating, these physical processes are interrupted by thoughts and emotions. Disturbed emotional states interfere with this natural process, throwing a person with an eating disorder out of balance physically, mentally and emotionally. Proulx (2008) comments, “Mindfulness is not a cookbook technique. It is a transformational journey” (70). Mindfulness practice breaks the cycle of control and loss of control and moves eating disordered patients toward regulation of emotional states and eventual acceptance and release (Cook-Cottone, Beck and Kane 2008; Baer, Fischer and Huss 2005; Chambers, Lo and Allen 2007). The technique of naming emotions that pass through the meditative state without judging or attempting to control them allows the meditation practitioner to carry the ability to identify and describe into every mindful, intentional moment. Patients with eating disorders often focus in unhealthy ways on the external—the shape and size of their bodies, or the way other people look at them—so exploring the internal world through mindful insight meditation refines the patient’s attention and takes them on that transformational journey (Wolever and Best 2009). By combining meditation with relaxation techniques and body awareness, mindfulness-based stress reduction helps patients work through pain and terminal illness. Pure meditation and related practices such as yoga and body scanning are now being studied as therapies for a wide variety of psychological and cognitive disorders including anxiety, panic attacks, depression, and even bi-polar disorder and mild schizophrenia (Smith et al. 2008). Disordered eating can be helped by learning these same skills (Baer, Fischer and Huss 2005; Chambers, Lo and Allen 2007; Corstorphine 2006). There is mounting evidence that mindfulness insight meditation may be helpful to patients with eating disorders. Perhaps this is because, as Smith et al. (2008) surmise, “a more accepting attitude toward one’s inner experience” and “enhanced self-monitoring and self-regulation” allow participants to let go of control, rather than losing control (256). The effectiveness of any therapy depends upon what the individual brings to the therapy and how much work she is willing to put in to see the desired results. Learning the seemingly simple skill of mindfulness can bring about dramatic changes in patients with eating disorders, both in their thinking about themselves and their relationship with food. References Baer, R., Fischer, S., and Huss, D. (2005). Mindfulness and acceptance in the treatment of disordered eating. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 23(4), 281-300. Chambers, R., Lo, B.C.Y., and Allen, N. (2007, 23 February). The impact of intensive mindfulness training on attentional control, cognitive style, and affect. Cognitive Therapy and Research, 32, 303-322. Cooke-Cottone, C., Beck, M., and Kane, L. (2008, March). Manualized-group treatment of eating disorders: attunement in mind, body, and relationship (AMBR). Journal for Specialists in Group Work, 33(1), 61-83. Corstorphine, E. (2006, November). Cognitive-emotional-behavioural therapy for the eating disorders: working with beliefs about emotions. European Eating Disorders Review 14(6), 448-461. Dryden, W., and Still, A. (2006). Historical aspects of mindfulness and self-acceptance in psychotherapy. Journal of Rational-Emotive and Cognitive Behavior Therapy, 24(1), 3-28). Kristeller, J. (2003). Mindfulness, wisdom and eating: applying a multi-domain model of meditation efforts. Journal of Constructivism in the Human Sciences, 8(2), 107-118. Martin, J. (1997). Mindfulness: a proposed common factor. Journal of Psychotherapy Integration, 7(4), 291-312. Proulx, K. (2008, Jan-Feb). Experiences of women with bulimia nervosa in a mindfulness-based eating disorder treatment group. Eating Disorders, 16(1), 52-72. Smith, B., Shelley, B., Dalen, J., Wiggins, K., Tooley, E., and Bernard, J. (2008, April). A pilot study comparing the effects of mindfulness-based and cognitive-behavioral stress reduction. Journal of Alternative and Complementary Medicine, 14(3), 251-258. Wolever, R. and Best, J. (2009). Mindfulness-based approaches to eating disorders. Clinical Handbook of Mindfulness. 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