Written by Dr. Kari Anderson from Green Mountain at Fox Run
Mindfulness describes the practice of being aware in the present moment, without judgment. And when mindfulness is applied to eating, the resulting practice is called mindful eating. Who wouldn’t benefit from such a practice?
In particular, mindful eating can benefit those individuals who are being treated for eating disorders. But the effectiveness of mindfulness when treating eating disorders depends on the level of readiness for such an intervention. Because eating disorders fall along a continuum of behaviors, there are significant differences from one end to the other end of the continuum, despite commonalities. For example, anorexia, in many ways, presents as “opposite” to binge eating disorder; therefore, the treatment needs to be different, at least in the early stages of recovery.
In general, those with binge eating disorder have less acuity and should be introduced to mindful eating early to help heal the relationship with food and eating pathology. On the other end of the continuum, those with anorexia have physical treatment goals that come before addressing eating pathology.
Treating Eating Disorders
Eating disorders can be seen as adaptive behaviors that become disorders. They are very logical, once the neurobiology, socio-cultural pressures and the self-regulatory response to stress that drives the behavior are understood. From a basic needs level, the Self Determination Theory simply explains disordered eating as a way to thwart or substitute needs. Eating disorders can be extremely effective until they’re not, and ultimately, eating disorders create more problems than they solve. Therefore, the sooner an ED sufferer learns how to meet their true needs, the better.
Cognitive behavioral therapy (CBT) has been the gold standard for treating eating disorders because it addresses the thoughts and emotions that lead to the behavior. Unfortunately, traditional CBT has shown only to be half as effective as it could be, largely due to the strong motivation needed in the treatment of eating disorders. The “resistance” that is often seen in this population is very responsive to an adapted form of CBT, called Dialectical Behavioral Therapy (DBT).
DBT was the first mainstream use of mindfulness to treat eating disorders. It shows a much higher effectiveness rate for those with binge eating and bulimia disorders than does traditional CBT. DBT addresses patient resistance, while offering solutions that positively influence regulation and stress management for those who turn to food for exactly those purposes.
Several mindfulness-based therapies have since emerged, known as Third Wave Cognitive (ACT, MBCT, MBSR, MB-EAT and the like). Surprisingly, treatment-resistant anorexia also can respond to Acceptance and Commitment Therapy (ACT), partly because it focuses on core values, not just thoughts and emotions. Regardless of the form of mindfulness-based treatment, the primary advantage lies in disengaging the stress reaction and anxiety that blocks the ability to change.
Mindful Eating in the Treatment of Eating Disorders
Humans are hardwired to react to stress, whether real or perceived, by fighting, fleeing or freezing. Many people turn to food to relieve stress, as eating can emotionally and physically calm us down by activating the “rest and digest” processes of the body.
Whether we have a hyperactive stress response or not, there are lots of things that create stress. But today’s dieting culture, judgmental and body-biased environments, and “no pain, no gain” exercise trends put tremendous stress on our bodies emotionally and physically. Together, they reinforce the cycle of turning to food to self-regulate.
Any therapies that can disengage the fear response and allow for our parasympathetic nervous system to help us find homeostasis will decrease the reactivity and impulsive nature around food.
One aspect of mindfulness that is tailor-made for eating disorders is that it helps manage the thoughts that lead to judgment. The “without judgment” part of the definition of mindfulness is essential because it diminishes our emotional reactions toward ourselves and others, keeping us out of an escalated state.
Furthermore, mindfulness theory has contributed to the emerging trend of self-compassion, which promotes the power of disengaging the judgmental mind and embracing oneself in the safety of self-nurturing. This repairs the breached bond necessary to relax into safety and begin to trust in humankind. The focus of being present in the moment disengages the fear of the future (worry) and regret of the past. When our mind is filled with the past and the future, our stress response is activated. And unless you are in a cage with a tiger, the present moment should be relatively void of stress.
Mindful eating means awareness in the present moment without judgment before, during and after eating. Eating pathology can be healed by introducing a healthy relationship with food, meeting needs of autonomy and competency with food. It simply is the best model for long-term sustainability of healing from an eating disorder because it counters the rigid rule-driven behaviors propelled by the internalized thin ideal found in most eating disorders.
However, mindful eating in the treatment of eating disorders can get tricky. A number of adaptive eating behaviors become automated by the brain and other complex feedback loops that regulate hunger and fullness. Regardless of why the initial behavior was developed, the body creates neuropathways and physiological adjustments that can override the basics of mindful eating. As such, interventions such as refeeding protocols or meal structure corrections may be necessary to restore the brain and physical health to a state where mindful eating can be effective.
For example, in the case of anorexia, allowing one to “wait for hunger” may result in further starvation. A person who binge eats has a diminished feedback mechanism to signal fullness; without a model as to what is “normal” eating, a binge-restrict cycle may be perpetuated.
Lastly, there are more important treatment interventions prior to the introduction of mindful eating, mainly those who are not weight restored or are engaged in active purging behaviors. Physical stabilization is of highest priority.
The treatment of eating disorders requires specialized care. If there is any question as to whether a client has an eating disorder, he or she must be referred to a Certified Eating Disorder Specialist (CEDS) or someone with similar training and experience. Likewise, mindful eating professional should refer their clients with eating disorders to a network of professionals — such as psychologists and registered dietitians trained to treat eating disorders. Eating disorder professionals who lack training in mindful eating must first understand that mindfulness is not merely a technique, but a full embodiment of a non-judgmental, open and compassionate awareness of their clients. This embodiment takes training, but most importantly, practice, a mindfulness practice.
The Big Picture
Practicing mindfulness addresses the need to disengage the stress response and create safe environments. At some point in their journey, those individuals healing from an eating disorder can benefit from a mindful practice and from mindful eating. The point at which one introduces mindfulness is largely determined by where a person is on the continuum of behaviors and their level of physical and emotional healing.
Dr. Kari Anderson has been treating eating disorders for 25 years, with particular emphasis on Binge Eating Disorder. She is the Executive Director for Green Mountain at Fox Run and Chief Clinical Director for the newly opened Women’s Center for Binge and Emotional Eating in Ludlow, Vermont. Her website is http://www.fitwoman.com.
This article originally appeared in the Summer 2016 issue of “Food for Thought”, a publication of The Center for Mindful Eating (www.thecenterformindfuleating.org).
by Matt Bartlett, LMFT of New Haven Residential Center
The holidays are a great time to enjoy family and friends and appreciate all that life has to offer. But they can also be a trying time, filled with stress, anxiety, unexpected temptations and a pace that can make your head spin. Along with all of the wonder and delight it’s important to remember that the holidays can be even more challenging for someone who is currently in treatment and experiencing their first home visit or transitioning home from residential treatment.
Tensions often run high at this time of year and as a member of the family works to assimilate back into the fold, it’s important to not get hung up on the issues or problems that took them out of the home in the first place. Families may find themselves reverting back to past behaviors as they interact and encounter some of the same problems. Rather than letting the past ruin this holiday season, take a look at five things to try to help prevent escalation at home:
1) Keep your sights set on the other person’s emotions and deal with emotions before anything else! The vast majority of our altercations happen when we are focused on behavior and words, rather than the emotions that drive them. We have to be less emotionally reactive as parents.
2) Avoid misappropriating responsibility. Let go of what you can’t control! Focus on what you can control. Remember, your daughter’s/son’s emotions, physiology, feelings, and thoughts are NOT within your control.
3) Try using “responsible language”. Speak in terms of what you are responsible for (your actions, your thoughts, sometimes your feelings), and what others are responsible for (their actions, their thoughts, sometimes their feelings).
● If you are struggling with perceiving who is responsible for what, try finishing each blaming statement you make with the phrase, “ . . . and I take responsibility for it!” until you get the point. It’s a little corny, but it’s fun and it works.
● Use the words “choice”, “choose”, and “choosing”, often.
● Instead of using the phrase, “I am angry,” use this new phrase, “I am choosing to anger myself,” OR, “I am choosing to be angry.”
● When your daughter/son hurts you, say things in this way: “Because you are choosing to do such-and-such, I am choosing to feel and do such-and-such.” (Be careful to be gentle when using this technique. It’s easy to use as a weapon.)
4) Negotiate rather than coerce:
● Identify and describe the problem so that you and your daughter/son agree on the description of the problem.
● Make an offer: “This is what I can bring to the table.”
● Allow your daughter/son to make an offer. Do not make offers for her/him.
● Working only with what is currently “on the table”, work to compromise.
● No one leaves until a compromise is reached. This could take a while!
5) Get creative! Stop doing the same thing. Try new approaches to old problems. HOW you influence is what’s most important.
Thanksgiving Tip Sheet from MEDA
SUPPORT: Make sure that you have someone you can lean on during this holiday season. You don’t have to manage Thanksgiving alone. You can always excuse yourself and text a friend, go outside and get some fresh air, walk the dog, or use a coping skill.
STRATEGIZE: What is your plan for the day? Make a schedule for yourself! Keep busy with planned activities. Don’t skip meals in “preparation” for the holiday. Maintain your regular eating schedule that has become a part of your recovery.
Say NO! If you’re feeling overwhelmed, it’s ok to decline invites to parties. Saying no will help you manage your commitments and schedule. If you avoid over-booking yourself, you may find more pleasure and satisfaction in the things you chose to do.
BE NICE TO YOURSELF: Take care of your basic needs like rest, regular food intake and hydration. Make yourself the #1 priority. If you slip into an old behavior, don’t be too hard on yourself. Allow yourself to enjoy the things you like. Reach out to someone you trust for support. Know your triggers and give yourself some slack. You are trying the best you can!
BREATHE: If you’re feeling overwhelmed, take a step back and take deep breaths. Always give yourself permission to step away for a moment or two.
STAY AWAY from known triggers. People or circumstances that have been difficult for you to manage in the past are likely to pose a challenge again. Be aware of these. Do not fall into the trap of underestimating your needs and overestimating the needs of others.
THANKSGIVING ISN’T ABOUT FOOD: Remember: Thanksgiving is really about being grateful for those around you or other positive aspects of your life. NOT ABOUT THE FOOD. Try to cultivate gratitude for the blessings in your life, whatever they may be, and cultivate gratitude for yourself and your hard work in recovery!
Written by Doug Bunnell, PhD, FAED, CEDS, Chief Clinical Officer of Monte Nido & Affiliates
Doug Bunnell is an expert clinician and leader in the eating disorder field. He brings over three decades of experience and a wealth of knowledge to his role as Monte Nido Chief Clinical Officer. He shares important information about treating males with eating disorders in this week’s blog post.
Most of what we know about eating disorders is based on what we know about women with eating disorders. Most of what we know about men with eating disorders is based on what we know about conventional models of masculinity. Most of what the two of us know about either of these topics is heavily influenced by our own gender, sexual identities, and ethnic backgrounds. These are the limitations that we, as psychotherapists, bring to the room when working with males- an underserved population in the world of eating disorder treatment. By examining the differences and similarities between how males and females with eating disorders present clinically we hope to shed some light on issues to be aware of as clinicians and how we can move towards a more comprehensive treatment of the eating disorder population.
Conventional wisdom tells us that one in ten people with eating disorders are male, but data suggests that 25% of diagnosable cases occur in males and that males have higher rates of disordered eating (Hudson et al., 2007). As is, unfortunately, easy to imagine, it is suggested that under reporting is a result of stigma, lack of sensitivity and detection, and gendered perceptions of eating dieting. The lower occurrence of eating disorders in males may, however, also be attributed to gendered differences in the risk and maintaining factors for eating disorders .
A difference in biology, brain organization and temperament, for example, are factors that appear to insulate men against risk. Mood disorder vulnerability also seems to put males at a lower risk as they have a greater tendency towards externalization as opposed to the female tendency for internalization- a trait that can serve as fuel for the eating disorder. Generally speaking, men present with less harm avoidance, less drive for thinness, and less body dissatisfaction; with what we know about eating disorders, this discrepancy should also account for the lower prevalence in the male population. That being said, it falls on us, as clinicians, to make sure we bring a certain awareness of clinical features and differences into our female-normed assessments to work against the risk of underestimating rates and severity.
One feature that is similar in both women and men with eating disorders is that men with ED present differently than men without ED- they may be struggling with depression or other impairments. The many ways that males and females differ in eating disorder presentation, however, lie in the manifestation of the illness; for that reason, it is of the utmost importance that we, as clinicians, maintain an acute awareness of our language during assessment. It is not as pertinent, for example, to assess for a “fear of fat” with a male client as males tend to idealize a body that has less fat and more muscle, therefore they tend to fear “softness” rather than “fatness”. A preoccupation with the need to be “lean” might be more relevant to males with eating disorders rather than the drive for “thinness” often seem in females. Additionally, males with eating disorders may present with use of steroids and human growth hormone. These factors are all important when assessing males on a drive for muscularity scale, male body checking scale, and obligatory exercise scale.
In addition to maintaining awareness in assessment of males, it is equally critical to maintain acute awareness of the language we use in the treatment of males. For a clinician accustomed to treating females, it is likely common to use very emotionally charged language such as “opening up”, “sharing”, and even referring to “fat as a feeling”. Not only are men generally less familiar with eating disorders than women, for better or for worse, men have been socialized by an unspoken male code to not be weak or vulnerable and to prioritize leadership, work, and self-sufficiency. While it is an adjustment from the way we work with female clients, it does not have to be an obstacle in helping our clients. Instead, we can work with decisional balance- weighing the pros and cons of change versus the pros and cons of no change with our male clients. By leaving what works for female clients at the door, we serve our male clients better and respect their sense of masculinity- however that may look for any one individual.
As individuals working with an already stigmatized disorder, it is important to constantly learn and keep an open mind and consider how much additional bravery it takes for a minority of an affected population to seek out our help. While we have made great strides in the treatment of eating disorders, there is always room for improvement. By embracing the difference in our experience as treatment providers, we will be able to work more successfully with this underserved population and further contribute to the work we all do to counter eating disorder stigma.
This article originally published on the Monte Nido site. (with this link: http://www.montenido.com/2016/11/09/men-with-eating-disorders/)
Written by Matthew C. Bartlett, M.Ed., LMFT Executive Director, New Haven Residential Treatment Center, Saratoga Springs Campus
So often we hear about how important it is to heal the individual. We can quote facts like roughly one percent of females will develop anorexia at some point in their life. Although it most commonly occurs in adolescent and young adult females, it can and does affect males at times. We can talk about genetic factors and family history. We can have proof that eating disorders often run in families. In fact, a close relative of someone with an eating disorder is 10 times more likely to develop an eating disorder than someone without any family history of an eating disorder. Plus there are environmental influences, stress events, the words of others, etc. All of these facts are relevant and true. And totally focused on the individual that suffers from the eating disorder.
What you don’t hear often is how eating disorders affect the family as a whole. How those stress events, those environmental influences, those statistics impact the whole family system. Too often we focus on healing the one and forget that she is a part of something larger. And if you ignore the bigger picture, that of the whole family system, the individual will be fighting her way back without the strong system that she’ll need to truly heal.
It is not uncommon for the eating disorder to become the center of the family system. As the person’s fears around her own eating, gaining weight and overall negative view of self increase, the family’s fears are increased as well. The pain that families and friends are faced with often come as a result of a broken relationship due to the impact that the eating disorder has had on the family system. At New Haven, we believe that when families can explore underlying issues, address individual needs and concerns, in a space that provides both emotional and physical safety, then they can find peace and lasting change.
Although eating disorders are difficult to treat, research shows that with effective family focused treatment, roughly one-half recover completely, while many others will experience intermittent periods of recovery and relapse. At New Haven we believe that the path to lasting healing and change comes through the experiences and security of loving, healthy relationships. Family based treatment for eating disorders is often the most effective path for young people struggling in this way.
From our therapists, cooks, teachers, to our clinically sophisticated residential staff, we all strive to ensure our young women and their families experience safe, secure and loving relationships. Through our interactions we model and teach values such as healthy boundaries, individual worth, respect, love, and empathy. The understanding of a personal locus of control empowers our students and their families to regain control and find purpose in relationships and life. This provides space for the creation of strong, healthy relationships with friends and family instead of it being filled with all the fears and challenges associated with anorexia.
New Haven’s family systems approach has proven results, with 87% of program graduates never readmitting to long-term residential treatment. And that’s what it’s all about. Ensuring that the entire family is healed.