Mindfully Eating Ourselves To Full



Dr. Suzanne Engelman

California Licensed Psychologist PSY7977
Board Certified in Biofeedback
Certified Thanatologist
Certified Animal Assisted Therapist

LOCATION:
30131 Town Center Drive
Suite # 268
Laguna Niguel, CA 92677

Office Phone:  (949) 460-4908 
FAX:  (949) 248-0421
Confidential email: srephd@hushmail.com
Suzanne R. Engelman, PHD, BCB, FT

Division 1 Briefings of the California Psychological Association

2012 175, 22-29

In the last issue of the CPA Division 1 Briefing, our colleague Steven Hickman, Psy.D wrote an excellent article on mindfulness, with its roots in Buddhism and meditation, noting because it is simply a “particular way of paying attention”, it has great generalizability outside of spiritual circles, as a way of increasing understanding and changing behaviors.

In the October issue of the APA publication Monitor on Psychology, two separate articles by Monitor staff Lea Winerman independently highlighted the topics of mindfully avoiding unwanted thoughts and eating better, mindlessly. So, needless to say, being mindfully mindless is on many minds. In working with people wanting to change eating behaviors, important and relevant aspect of change may also include mindfulness, i.e. cultivating the moment-to-moment awareness in which inner experience may be relabeled without judgment, and impulses to act upon experiences are reduced.         

In so far as sub-threshold levels of eating disorder attitudes are prevalent in the general population, in addition to clinically diagnosable anorexia nervosa, bulimia, and eating disorders not otherwise specified, the potential usefulness of this tool is immense (Lavender, Gratz, Tull, 2011).

This article briefly summarize some of the literature on mindfulness and its specific application to changing eating behaviors.  A clinical mindfulness application is then presented as an example of how to effectuate change in eating behaviors with patients.        

“Emotional-eating” is a term to describe eating in response to emotions, rather than hunger cues (Arnow, Kenardy & Agras, 1995). Emotional eating is a type of “emotional dysregulation”, which is a maladaptive attempt to cope with stressful and uncomfortable affective or cognitive experiences (Lavender, Gratz, Tull, 2011). With emotional dysregulaton, feelings of failure, lack of control, low self-esteem and depression may arise; physical issues may include long-term weight gain, obesity, and weight related medical problems such as diabetes (Arnow, Kenardy & Agras, 1995). 

Treatments of eating disorders have frequently focused on cognitive approaches of gaining control over, and changing dysfunctional thinking. In contrast, mindfulness-based approaches focus more on the totality of thoughts, feelings, and sensations rather than thoughts alone ( Kabat-Zinn, 1990). Mindfulness encourages self-acceptance, and non-reactivity, moment-by-moment, which facilitates self-examination of one’s behaviors with non-judgemental awareness. 

The self-awareness component of mindfulness assists people in differentiating between subtle emotional distress and subtle hunger pangs, and coming to see that feelings and thoughts are not necessarily facts to be acted upon, but rather passing mind-states. Such “mindfulness” components have been shown to be inversely related (i.e. negatively correlated and therefore protective) of the emotional avoidance and emotional dysregulation associated with eating pathology (Lavender, Gratz, & Tull, 2011).

Mindfulness in and of itself may provide an alternative method of reducing stress that replaces reflexive eating behaviors in response to stressful events. Other research  on mindfully-based treatments for eating disorders indicates binge eating is reduced when people: increase self-acceptance and reduce state anxiety (Smith, Shelley, Leahigh, &Vanleit, 2006); become more attentive to eating patterns (Engstrom, 2007); attend to the self and body in an experiential way (Rawal, Enayati, Williams, & Park, 2009); control responses to varying emotional states, make conscious food choices, develop awareness of hunger and satiety cues, and cultivate self-acceptance (Kristeller, & Wolever, 2010).

In summary, clinical research abounds with examples supporting the use of mindfulness as being effective in reducing eating pathology in both clinical and sub-clinical populations.

An intervention, based on materials included in the Mindfulness-Based Stress Reduction (MBSR) (Santorelli, & Kabat-Zinn, 2009) curriculum, will now be presented. I have found this mindfulness intervention useful in assisting patients in changing eating behaviors by helping them increase self-awareness of eating behaviors, within a framework of engendering receptive gentle curiosity, non-judgementalness, and non-reactivity. Patients who have undergone lap-band procedures and are having difficulty maintaining weight loss, as well as those trying to “lose weight” or “get my eating under control” have reported that this tool assists them to significantly change their eating behaviors, day-to-day.                                                                                 

A Mindful Eating Intervention:

As part of ongoing psychotherapy, I begin the discussion about a “different tool” at least a week before implementation, by assisting the patient in recognizing the specific eating dysfunctions and accompanying emotional dysregulation components present in his or her life. I obtain informed consent with the patient, by identifying a strategy I would like to offer them which may be useful in modifying problematic eating behaviors. This is important to cover, especially if the intervention represents a shift away from your usual way of working with this particular patient, and if mindfulness or meditation are not already part of the patient’s day to day repertoire. 

A week before the eating exercise, the patient and I together identify a small piece of food like a raisin or grape, that would be an appropriate object of contemplation. The patient brings several pieces of the identified food to our next meeting. The day of the actual intervention, I may begin the session with some brief relaxation work to assist the patient in moving to a different and slower pace of experience.

In my practice I regularly utilize mindful breath work, and may work with patients to become more aware of the sensations of the inhale and exhale of the breath; the rise and fall of the abdomen, etc. In this particular eating behavior application, I may add the stomach to bring into the focus of awarenss, by breathing “into” the stomach.  How does your stomach feel? Are your noticing hunger pangs or a sense of fullness?   After this, I guide the patient through a sensory awareness exercise of noticing the facets of the raisin ( or other food); noticing the ridges and valleys; feeling the texture.  The raisin’s “belly buttom” brings forth the idea of interconnectedness with a larger whole. (Santorelli & Kabat-Zinn, 2009)

The raisin came from a vineyard, and a vine is in a geographic region, the vine is sustained by sun, rain and is rooted in the ground, the ground provides many other nutrients, many others may have eaten raisins from this particular vine, etc.         

In the next step, we move to the moment-to-moment awareness of the eating experience, letting go of “thinking about eating”, and instead being with the sensations of eating.  This involves increasing awareness of all the senses, which are normally involved in our everyday eating experience, but seldom consciously attended to.

Slowly moving the raisin to the mouth; noticing the kinesthetic feeling and integration of the arm, fingers, the opening of the mouth; noticing the sense of smell changing as the raisin approaches the lips, the feel of the raisin as it enters the mouth; noticing the feel, sound and taste of the raisin as it rests on the tongue, is moved by the tongue; the sound and feeling of the raisin as it is chewed and swallowed; the sensations felt in the process of swallowing, and added visualization of the raisin proceeding to the stomach.

The exercise may be completed with several more raisins, noticing inter-raisin differences. Instructions to generalize the increased and non-judgemental awareness to other foods at other times and situations are provided to complete the intervention. It is always important to follow-up in the next session, to find out how this experience generalized to the day-to-day experience of eating behaviors and to add any further instructions to facilitate awareness.

In this way, patients are encouraged to develop a healthier relationship with their food that is based on awareness, rather than habitual reactivity.  Optimally, this changed food relationship could generalize to all aspects of their lives, creating greater healing and self-understanding, and less reactivity to thoughts and feelings.

Suzanne R. Engelman, PH.D., BCB, FT is a licensed clinical psychologist with a private practice in Laguna Niguel, CA.  Dr. Engelman is a certified Thanatologist and Animal Assisted Therapist. Practice areas include the biopsychosocial and spiritual aspects of patients coping with medical problems including pain, cancer and life-threatening illness, obesity; bereavement and stress. Dr. Engelman is on the medical staff at St. Joseph Hospital, Orange, CA and is the author of numerous articles and editor of Life Threatneing Illness: Mind/body approaches.  Further information about Dr. Engelman may be found on this website www.healthpsychologynow.com or by calling 949/460-4908. 

References

 Arnow, B., Kenardy, J., & Agras, W.S. ( 1995). The Emotional Eating Scale:  The development of a measure to assess coping with negative affect by eating. International Journal of Eating Disorders, 18, 79-90.

Engstrom, D. (2007). Eating mindfully and cultivating satisfaction: Modifying eating patterns in a bariatric surgery patient, Bariatric Nursing and Surgical Patient Care, 2(4), 245-250.  doi: 10.1089/bar.2007.9954

Hickman, S. (2011).  Happy to drink old wine in these new mindfulness bottles, CPA Division 1Briefing, 173, 7-9.

Kabat-Zinn, J. (1990).  Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York: Delta.

Kristeller, J. L., & Wolever, R. (2010). Mindfulness-based eating awareness training for treating binge eating disorder: The conceptual foundation, Eating Disorders, 19(1),49-61.

Lavender, J. M., Gratz, K. L., Tull, M.T. (2011).  Exploring the relationship between facets of mindfulness and eating pathology in women, Cognitive Behavior Therapy, 40(3), 174-182.

Rawal, A., Enayati, J., Williams, M., Park, R., (2009). A mindful approach to eating disorders, Healthcare Counseling and Psychotherapy Journal, 9(4) 16-20.

Santorelli, S., &  Kabat-Zinn, J. (Eds). (2009)  Mindfulness-based stress reduction (MBSR) Professional Education and Training, Center for Mindfulness, University of Massachusettes Medical School, MA.

Smith, B.W., Shelley, B.M., Leahigh, L., & Vanleit, B. (2006).  A Preliminary study of the effects of a modified mindfulness intervention on binge eating, Complementary Health Practice Review,11(3), 133-143.

Winerman, L. (2011). Suppressing the ‘white bears’, Monitor on Psychology, 42(9), 45.

Winerman, L. (2011). How to eat better-mindlessly, Monitor on Psychology, 42(9),46-47.