Journal of Rational-Emotive & Cognitive-Behavior Therapy ( 2006) DOI: 10.

1007/s10942-005-0015-9

MINDFULNESS AND ACCEPTANCE IN THE TREATMENT OF DISORDERED EATING

Ruth A. Baer Sarah Fischer Debra B. Huss
University of Kentucky, USA

ABSTRACT: Mindfulness and acceptance-based approaches to the treatment of clinical problems are accruing substantial empirical support. This article examines the application of these approaches to disordered eating. Theoretical bases for the importance of mindfulness and acceptance in the treatment of eating problems are reviewed, and interventions for eating problems that incorporate mindfulness and acceptance skills are briey described. Empirical data are presented from a pilot study of mindfulness-based cognitive therapy adapted for treatment of binge eating. KEY WORDS: mindfulness; acceptance; binge eating; eating disorders; meditation; mindfulness-based cognitive therapy.

Disordered eating patterns, including binging, purging, and the relentless pursuit of extreme thinness, have been recognized for well over a century (Stunkard, 1993). In recent decades, several treatment approaches have been developed which now enjoy considerable empirical support, especially for binging and purging. The most prominent of these are cognitive-behavioral therapy (CBT; Apple & Agras, 1997; Fairburn, Marcus, & Wilson, 1993), interpersonal therapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984), and dialectical behavior therapy (DBT; Linehan, 1993a, b), all of which have shown clinically signicant effects in randomized trials with

Author correspondence to Ruth A. Baer, Dept of Psychology, University of Kentucky, 115 Kastle Hall, Lexington, KY, 40506-0044 USA; e-mail: rbaer@uky.edu.
2006 Springer Science+Business Media, Inc.

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individuals suffering from bulimia nervosa or binge eating disorder (Garner, Rockert, Davis, & Garner, 1993; Safer, Telch, & Agras, 2001b; Telch, Agras, & Linehan, 2001; Wiley et al., 1993). Although many participants in these treatments show substantial improvements, some do not, suggesting that additional efforts to improve treatment efcacy are needed. Recently, several authors have suggested that acceptance-based methods for treating disordered eating merit increased attention (Wilson, 1996). The efcacy of mindfulness-based interventions, which encourage nonjudgmental acceptance of experience, is gaining increasing empirical support (Baer, 2003). Mindfulness is a way of paying attention that is taught through the practice of meditation or other exercises, in which participants learn to regulate their attention by focusing nonjudgmentally on stimuli such as thoughts, emotions, and physical sensations (Kabat-Zinn, 1982, 1990). Participants learn to observe these stimuli without evaluating their truth or importance, and without trying to escape, avoid, or change them. Mindfulness practice is thought to result in increased self-awareness and acceptance, reduced reactivity to thoughts and emotions, and improved ability to make adaptive choices about responding to aversive experiences (Linehan, 1993a,b). Although the application of mindfulness and acceptance-based approaches to disordered eating has been investigated in only a few studies, early results are promising. DBT, as adapted for eating disorders, includes training in mindfulness skills, along with several change-based strategies such as emotion regulation and behavioral chain analysis, and has shown good success rates. Several pilot and case studies using other mindfulness and acceptance-based approaches also have found encouraging reductions in disordered eating (Baer, Fischer, & Huss, 2005; Heffner, Sperry, Eifert, & Detweiler, 2002; Kristeller & Hallett, 1999). These approaches include mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002), acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) and mindfulness-based eating awareness training (MB-EAT; Kristeller & Hallett, 1999). This paper has several purposes. After a brief summary of the characteristics of eating disorders, theoretical foundations for the application of mindfulness and acceptance-based treatments to disordered eating are reviewed. We describe two theoretical models of disordered eating, and discuss how mindfulness practices may affect the processes that initiate and maintain pathology in both of them. Next,

Ruth A. Baer, Sarah Fischer, and Debra B. Huss

we provide an overview of mindfulness and acceptance-based treatments that have been applied to disordered eating. Finally, we present a pilot study that utilizes MBCT in the treatment of women with binge eating disorder.

EATING DISORDERS The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; 2000) recognizes two primary eating disorders: anorexia nervosa (AN) and bulimia nervosa (BN). It also provides a category for eating disorders not otherwise specied (EDNOS), which includes binge eating disorder (BED), subthreshold versions of AN and BN, and other disordered eating patterns. The primary feature of AN is extreme restriction of food intake. Diagnostic criteria include refusal to maintain a minimally normal body weight, amenorrhea, disproportionate fear of weight gain, and disturbance in the evaluation of body weight and shape. BN includes frequent binge eating episodes and the use of compensatory behaviors to prevent weight gain, such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise. In both AN and BN, self-evaluation is unduly inuenced by body shape and weight. BED includes frequent binge eating but without the compensatory strategies typical of BN. BED is believed to be more common than either AN or BN (Millar, 1998). Subthreshold cases of AN, BN, and BED have been reported to be quite common (Herzog, Keller, Lavori, & Sacks, 1991; King, 1991), and to include signicant levels of distress and impairment. For example, Striegel-Moore et al. (2000) found that a community sample of women with subthreshold BED did not differ from those meeting full criteria on measures of shape and weight concern, dietary restraint, or psychiatric distress. Thus, the evidence suggests that eating disturbances cause signicant distress and dysfunction in the general population, particularly among women.

MODELS OF DISORDERED EATING Cognitive Behavioral Model The cognitive behavioral model of the development and maintenance of bulimia and binge eating describes a transactional chain of

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events that begins with distorted thoughts about thinness and dieting, especially in individuals with low self-esteem and concerns about body shape and weight. Initially, these individuals perceive social or interpersonal pressure to be thin and develop maladaptive cognitions or beliefs about thinness. Distorted beliefs about the benets of thinness are hypothesized to lead to strict dieting. The resulting caloric deprivation causes hunger, which increases the likelihood of binge eating. However, because binge eating violates dietary restrictions, binges lead to distress, guilt, lowered self-esteem, and increased concerns about body shape and weight. In order to compensate for the unwanted effects of the binge, the individual may engage in purging behavior in the form of self-induced vomiting, laxative or diuretic use, or excessive exercise. These behaviors typically are followed by renewed determination to restrict food intake (Apple & Agras, 1997). Central to this model is the hypothesis that distorted cognitions about dieting and thinness perpetuate restriction of food and, thus, binge eating and purging behavior. A sizable body of empirical evidence supports this assertion, especially for women. Media images of increasingly thinner women are believed to create social pressure to be thin in order to be attractive and successful. Adoption of these societal standards, described as thin-ideal internalization (Stice, 2002; Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004) has been shown in experimental and longitudinal studies to lead to increases in bulimic symptoms (Stice, 2002). In addition, Thompson et al. (2004) reported that bulimic women endorse the thin-ideal more strongly than non-bulimic women. Body dissatisfaction, dened as negative subjective evaluation of physical attributes (Stice and Shaw, 2002), is also thought to increase with endorsement of the thin-ideal. This relationship has been demonstrated in laboratory studies in which exposure to media images of thin models leads to increased body-focused anxiety, especially in women who endorse the thin-ideal (Halliwell & Ditmar, 2004). The application of expectancy theory to the study of eating disorders provides additional empirical evidence for the role of distorted cognitions in disordered eating behavior. Response outcome expectancies are beliefs that a given behavior will result in a given outcome (Bolles, 1972; MacCorquodale & Meehl, 1953; Rotter, 1954). Expectancies are formed as a result of ones learning history, either through direct learning experiences or through modeling by others, and are thought to be causally linked to behavior. Outcome expectancies regarding thinness include I would be more self-reliant and

Ruth A. Baer, Sarah Fischer, and Debra B. Huss

independent if I were thin, and I would feel more capable and condent if I were thin (Hohlstein, Smith, & Atlas, 1998). Individuals with AN and BN endorse outcome expectancies for thinness at much higher rates than individuals without these disorders (Hohlstein, et al., 1998). Furthermore, in a recent longitudinal study, Smith, Simmons, Annus, and Hill (2005) showed that expectancies regarding thinness predicted the development of symptoms of BN in a sample of middle school girls. In addition to distorted thoughts about the importance of thinness, many individuals with eating disorders show maladaptive thoughts about food and eating patterns. For example, many have self-imposed rules about foods that must always be avoided (such as ice cream or cookies). A single violation of a dietary rule may be considered a complete failure of the entire diet. This thought often leads to binge eating, which increases the believability of thoughts of failure. The importance of cognition in the initiation and maintenance of disordered eating leads us to hypothesize that mindfulness and acceptance-based treatment strategies would be useful in addressing these symptoms. A goal of mindfulness training is to cultivate nonjudgmental observation and acceptance of sensations, cognitions, and emotions. Mindfulness-based approaches typically do not include traditional cognitive therapy strategies designed to challenge or change the content of thoughts. Instead, mindfulness training encourages a decentered view of thoughts, in which thoughts are viewed as uctuating and transient mental events, rather than factual or accurate representations of reality. This decentered view, also known as defusion in ACT, should reduce the believability of thoughts and promote the realization that thoughts do not necessitate specic behaviors. For example, a client may have distorted thoughts about the consequences of breaking a dietary rule, which typically would trigger binge eating or increased restriction of eating. However, adopting a mindful stance should facilitate the understanding that these thoughts are transient, may be replaced with other thoughts, and do not necessarily reect reality or require any particular behavior, thus reducing the clients perceived need to take action to correct the fact that she has blown her diet. Emotion Regulation Model Other authors have hypothesized that disordered eating is the result of maladaptive emotion regulation. For example, Heatherton

Journal of Rational-Emotive & Cognitive-Behaviour Therapy

and Baumeister (1991) suggest that binge eating is motivated by a desire to escape from aversive emotional states related to perceived inability to meet high personal standards. Similarly, Wiser and Telch (1999) suggest that binge eating functions to reduce unpleasant emotional states in individuals who lack more adaptive emotion regulation skills. Empirical evidence supports this model as well. First, trait neuroticism (the tendency to experience negative affect) is a broad risk factor for eating disorders (Stice, 2002). Hence, individuals with eating disorders may experience negative mood states more often than those without. Second, women with BN endorse the belief that eating alleviates distress, and coping motives are positively related to food consumption (Hohlstein et al., 1998; Jackson, Cooper, Mintz, & Albino, 2003). Studies using daily diary methods nd that women with binge eating problems tend to binge more on days when stressors occur, and to rate those stressors as more distressing than women who do not binge (Crowther, Snaftner, Bonifazi, & Shepherd, 2001). Binge eating women also tend to label as a binge any eating that occurs in response to negative emotion, even if the quantity eaten was not large (Telch, Pratt, & Niego, 1998). Experimental studies of mood induction show that individuals tend to eat in response to negative affect (Agras & Telch, 1998; Stice, 2002), and Fischer, Smith, & Anderson (2003) have shown that a facet of impulsivity known as urgency (tendency to act rashly when distressed) is strongly correlated with binge eating. In sum, individuals with eating disordered behavior may experience more negative affect than non-disordered individuals, tend to believe that eating will help reduce distress, and tend to eat in response to distress. These pieces of evidence support the conclusion that maladaptive attempts to regulate emotions are related to disordered eating behavior. Experiential avoidance is a related concept dened as unwillingness to experience negative feelings, sensations, or thoughts, and taking action to alter these experiences or the contexts in which they occur, even when doing so is maladaptive (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). This construct is positively correlated with psychopathology, and negatively associated with mindfulness constructs such as acceptance and mindful action (Hayes, et al., 1996; Baer, Smith, & Allen, 2004). In a discussion of the role of emotion regulation in ACT, Blackledge & Hayes (2001) contend that negative thoughts and emotions, though potentially distressing, are not innately harmful and do not have to be changed, and that much maladaptive and pathological behavior is the result of counterproductive

Ruth A. Baer, Sarah Fischer, and Debra B. Huss

attempts to avoid these experiences, using strategies such as substance abuse, dissociation, or avoidance of people, places, or situations that elicit them. In fact, laboratory studies of suppression of thoughts and emotions show that the more one tries to avoid these phenomena, the more likely one is to experience them (Clark, Ball, & Pape, 1991; Gross, 2002; Gross & John, 2003). Thus, theory and research ndings suggest that many cases of disordered eating could be viewed as failed attempts to regulate aversive internal experiences. Although individuals with eating disorders may believe that eating will alleviate distress, and may feel momentary relief as they binge, they also experience an increase in negative affect after a binge is completed (Apple & Agras, 1997). This pattern clearly suggests that eating is not an effective long-term strategy to cope with negative emotion, but is instead used as short-term experiential avoidance. Several mechanisms have been suggested by which mindfulness practice may promote more effective coping with aversive emotions. First, mindfulness may serve as exposure to emotions. Clients are encouraged to observe, accept, and experience emotions without attempting to change them. Exposure to negative emotion in this way may reduce impulsive, maladaptive reactivity to distress. Second, mindfulness strategies encourage clients to view emotions as transient events that do not require specic behaviors. The knowledge and experience that emotions are eeting may reduce the need to act on them immediately. In addition, a decentered view of emotions may help prevent the experience of secondary emotional reactions. Linehan (1993a, b) describes secondary emotional reactions as emotions that arise in response to another emotion. For example, a client may feel angry about having been treated unfairly, and then experience guilt about feeling angry. The experience of guilt may inuence the client to behave differently in response to the situation that originally caused the anger. That is, instead of taking steps to obtain fairer treatment, the client may keep silent in the belief that feeling angry is wrong. The acceptance of emotions as they appear may interrupt this chain of events by enabling the client who feels angry to notice the anger, refrain from self-criticism or maladaptive attempts to get rid of it, accept the reality that angry feelings are present, and take time to consider how to respond. In general, acceptance of emotion implies that it is not necessary to try to change the emotion immediately, and promotes the ability to make more adaptive choices about how to respond when experiencing strong

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emotional states. If a clients immediate response to distress is to eat, a mindfulness and acceptance-based approach may facilitate more adaptive choices. MINDFULNESS AND ACCEPTANCE-BASED TREATMENTS FOR DISORDERED EATING Several interventions incorporating mindfulness and acceptancerelated approaches to disordered eating have been introduced, and empirical support for their efcacy is increasing steadily. They include DBT, MBCT, ACT, and MB-EAT. Dialectical behavior therapy (DBT; Linehan, 1993a, b) was developed to treat borderline personality disorder, but in recent years has been adapted for application to bulimia and binge eating disorder (Safer, Telch, & Agras, 2001a, b; Telch, Agras, & Linehan, 2000, 2001). DBT for eating disorders consists of 20 weekly sessions and has been applied in both group and individual formats. The rationale for this approach is based on the emotion regulation model described earlier (Wiser & Telch, 1999), which posits that binge eating functions to reduce aversive emotional states, and that by diverting attention from negative affect, binge eating temporarily reduces distress and thus is negatively reinforced. This version of DBT is designed to improve participants ability to manage negative affect adaptively and includes training in mindfulness, emotion regulation, distress tolerance, and behavioral chain analysis skills, which are applied to binge eating episodes. The mindfulness skills are taught to counteract the tendency to use binge eating to avoid awareness of negative emotional states. These skills encourage nonjudgmental and sustained awareness of emotional states as they are occurring, without reacting to them behaviorally. That is, participants learn to observe their emotions without efforts to escape them and without self-criticism for having these experiences. This state of mindful awareness facilitates adaptive choices about emotion regulation and distress tolerance skills that could be used in place of binge eating. Several clinical trials have provided strong support for this adaptation of DBT (Telch et al., 2000, 2001; Safer et al., 2001b). Acceptance and commitment therapy (ACT; Hayes et al., 1999) is based on an experiential avoidance model, which suggests that many forms of disordered behavior are related to attempts to avoid or escape aversive internal experiences. ACT emphasizes nonjudgmental acceptance of thoughts and feelings while changing overt behavior to

Ruth A. Baer, Sarah Fischer, and Debra B. Huss

work toward valued goals and life directions. A recent clinical case study (Heffner et al., 2002) and self-help manual (Heffner & Eifert, 2004) describe the application of ACT to anorexia nervosa. The intervention includes several mindfulness and acceptance-based strategies for working with fat-related thoughts, images, and fears. For example, the thought parade is a mindfulness exercise in which the participant imagines that her thoughts are written on cards carried by marchers in the parade. Her task is to observe the parade of thoughts, such as Im a whale and my stomach is gross (Heffner et al., 2002, p. 234) as they come and go, without becoming absorbed in them, believing them, or acting on them. This exercise encourages the nonjudgmental observation of cognitions, rather than engaging in anorexic behaviors in reaction to such thoughts. Similarly, in the bus driver exercise, the participant imagines that she is the driver of a bus, which represents her movement toward valued life goals. Fatrelated thoughts are conceptualized as passengers on the bus, who demand that she change direction and drive the bus down the anorexia road (Heffner et al., 2002, p. 235). This exercise encourages the ability to allow negative thoughts to be present without acting in accordance with them, and while maintaining movement in valued directions. As adequate nutrition generally is required to maintain the energy to move in these directions (such as being a good friend or doing good work), an important feature of the intervention is the clarication of the patients most important values. Mindfulness-based eating awareness training (Kristeller & Hallett, 1999) was developed to treat binge eating disorder and is loosely based on the Mindfulness-Based Stress Reduction (MBSR) program develop by Kabat-Zinn (1982, 1990). It is conducted as a 9-session group intervention and includes several types of mindfulness and meditation exercises. Breathing and body scan meditations promote awareness and acceptance of bodily sensations, including hunger and satiety cues. Other exercises involve mindful eating of foods typically included in binges, such as cookies and cake, focusing on eating behaviors, emotions associated with eating, and the textures and tastes of the foods eaten. Mini-meditations also are taught, in which participants learn to stop for a few moments at key times during the day to practice nonjudgmental awareness of thoughts and feelings. Efcacy of MB-EAT has been supported in an uncontrolled trial (Kristeller & Hallett, 1999) and in a recent controlled trial (Kristeller, unpublished data).

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MBCT is derived largely from MBSR and was developed for the prevention of relapse of major depressive episodes. Two randomized trials have shown that MBCT substantially reduces the risk of relapse in individuals with three or more previous episodes (Ma & Teasdale, 2004; Teasdale, Williams, Soulsby, Segal, Ridgeway, & Lau, 2000). Adaptation of MBCT for application with binge eating has been described in a recent case study (Baer et al., 2005). Additional information about this approach is provided in the following section, in which we describe a small pilot study.

PILOT STUDY: MBCT ADAPTED FOR BINGE EATING This study examines the application of MBCT to BED. We chose MBCT because of its empirical support, and because we wished to conduct a strong test of the idea that mindfulness training can inuence binge eating in the relative absence of other change-oriented treatment strategies. MBCT emphasizes intensive mindfulness practice. It does not teach traditional cognitive change procedures, such as identifying cognitive distortions, examining evidence for and against thoughts, or generating more rational thoughts. It also does not teach skills for modifying emotions or for improving problem-solving, interpersonal interactions, or diet and exercise behaviors. The absence of these change strategies is an important difference between MBCT and most other empirically supported treatments for eating problems, which include a higher number of change strategies. In accordance with the theoretical models discussed earlier, we hypothesized that MBCT would lead to increased ability to refrain from binge eating in the presence of negative thoughts and emotions, but might not have substantial impact on their content, frequency, or intensity, as such changes are not targeted by the intervention. Recruitment, Screening, and Assessment The study was advertised on yers posted in the community and through letters to local therapists. Potential clients who contacted the treatment center where the study was conducted were asked to complete a phone screening interview. Clients were screened for AN, BN, current major depressive episode, substance abuse or dependence, suicidal or homicidal ideation, borderline personality disorder, and

Ruth A. Baer, Sarah Fischer, and Debra B. Huss

psychosis. Clients were invited to the clinic for an intake session if they engaged in episodes of binge eating, did not have the disorders listed above, and were not currently receiving other psychotherapy. The intake session included the following measures. The Eating Disorder Examination (EDE; Fairburn & Cooper, 1993) is a structured interview that provides DSM-IV diagnoses of AN, BN, BED, and EDNOS. The Binge Eating Scale (BES; Gormally, Black, Daston, & Rardin, 1982) is 16-item measure of binge eating characteristics. The Eating Expectancy Inventory (EEI; Hohlstein et al., 1998) is a 34item Likert-type inventory with ve subscales measuring learned expectancies for reinforcement from eating. The three subscales shown in the validation sample to discriminate a bulimic group from normal controls (eating helps manage negative affect, leads to feeling out of control, and alleviates boredom) are reported in this study. An early version of the Kentucky Inventory of Mindfulness Skills (KIMS; Baer et al., 2004) was used to assess two facets of mindfulness: observation and nonjudgmental acceptance. Participants also completed the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996). Each week during treatment, clients completed food diaries in which they recorded all foods they ate, briey described the circumstances, and noted whether they considered each eating episode a binge. Clients also completed homework record sheets on which they noted mindfulness exercises completed each day. At the beginning of alternate treatment sessions, clients completed the BDI-II. Two to four weeks after completing treatment, clients returned for a posttreatment assessment, where the same measures completed at intake were re-administered. Participants Ten women participated in treatment. Nine were white, one was biracial. Age ranged from 23 to 65 years. Body mass index ranged from 22 to 40. Six of the clients met full DSM-IV criteria for BED. The others met all criteria for BED except for the frequency of objective binge episodes, having engaged in three to ve binges during the month prior to treatment. Six of the participants had previously been in some form of psychotherapy, but only one had received treatment for an eating disorder. One participant had received formal training in meditation. Two participants had previously experienced symptoms of bulimia and had also been previously diagnosed with alcohol abuse or dependence. One participant had a diagnosis of Bipolar II

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disorder. Six of the 10 women completed treatment and post-treatment assessments. The remaining clients attended ve or more sessions, but were not available for post-treatment assessment. Results are presented only for the six clients who provided post-treatment data. Treatment Treatment was conducted by two co-therapists. The senior co-leader was a licensed clinical psychologist and faculty member, and the other was a Masters-level graduate student in clinical psychology. Segal et al. (2002) recommend that leaders of MBCT be engaged in an ongoing mindfulness practice. The senior co-leader has been so engaged for several years. The Masters level therapist agreed to practice the meditation exercises assigned to the clients on a daily basis during the course of the treatment. Treatment followed closely the procedures and strategies described in the MBCT manual (Segal et al., 2002). Several adaptations were made. First, although the manual describes an 8-session program, we distributed the material across 10 sessions, in order to allow comparison to a 10-session cognitive-behavioral protocol in future research. At points where the MBCT manual describes material specic to depression, we substituted material appropriate to binge eating. For example, discussion of DSM-IV criteria for BED was substituted for discussion of criteria for major depressive disorder. For a discussion of automatic thoughts, we used thoughts common in binge eating individuals. Participants were treated in three small groups. Mindfulness exercises were practiced and discussed during every session. In the body scan, attention is focused sequentially on numerous parts of the body, and sensations are observed nonjudgmentally. If thoughts and emotions arise, these are noted briey and attention is returned to the body. Mindful stretching and walking encourage awareness of sensations during slow, gentle movements. During mindful eating, participants observe the sensations and movements associated with eating, as well as thoughts and emotions that arise. In sitting meditation, awareness is focused sequentially on several targets, including breathing, bodily sensations, sounds, thoughts, and emotions. Participants are encouraged to observe and accept whatever enters their awareness. After a few weeks, instructions for sitting meditation were expanded to include intentionally bringing to mind a problem or difculty related to binging, and observing

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associated sensations and emotions without trying to change or eliminate them. Generalization of mindfulness to daily life is encouraged with the three-minute breathing space, in which participants practice mindful awareness of internal experience for short periods during their normal day. Homework included daily practice of one or more mindfulness exercises. Clients were provided with audiotapes to guide their practice, and were encouraged to practice without tapes during the nal few weeks. Several sessions included cognitive therapy exercises that teach an accepting, nonjudgmental, and non-reactive attitude toward cognitions. Relationships between situations, thoughts, and emotions were discussed, with emphasis on the concepts that thoughts are not facts, and that ongoing moods can inuence interpretations of events. Recognition of automatic thoughts related to eating also was discussed. A small number of behavior change strategies are included in MBCT, including identifying activities related to feelings of mastery and pleasure and making plans to increase participation in these while reducing activities related to negative thoughts and moods. An action plan for the prevention of binge eating was developed, emphasizing use of mindfulness skills to recognize triggers for binge eating, observing sensations, thoughts, and feelings and allowing them to come and go, and choosing what to do next. Results Pre- and post-treatment scores are presented in Table 1. Where possible, effect sizes were calculated by dividing the difference between pre- and post-treatment scores by the standard deviation of each instruments normal control sample, thus quantifying the magnitude of change in standard deviation units. Positive effect sizes indicate change in the therapeutic direction. Objective Binges. According to Fairburn and Cooper (1993), an objective binge includes an amount of food larger than most people would eat in a discrete time period. A subjective binge is seen by the participant as excessive, but does not include a large amount of food. Both types include a feeling of loss of control. Objective binges decreased for all participants. One participant was abstinent of objective binges at post-treatment, while three others had reduced to one objective binge per month.

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Table 1 Pre- and Post-treatment Scores and Effect Sizes

Measure Objective binges per month (EDE) Subjective binges per month Eating Disorder Examination subscales Restraint eating concern weight concern shape concern Binge Eating Scale Eating Expectancies Inventory manages negative affect leads to feeling out of control alleviates boredom Kentucky Inventory of Mindfulness Skills Observation nonjudgmental acceptance Beck Depression Inventory
*

Pre 15.67 .68 2.50 2.98 3.13 3.70 25.80 5.25 5.40 5.45 71.33 35.67 12.20

Post 4.0 4.0 2.10 1.77 3.34 3.35 18.40 4.64 4.40 5.85 81.00 49.00 9.20

Effect size* N/A N/A .42 2.90 ).28 .41 .88 .61 .96 ).26 .72 1.58 .30

magnitude of change calculated in standard deviation units of the instruments normative sample, positive effect size indicates change in the therapeutic direction.

Subjective Binges. A different pattern was noted for subjective binges. Despite the reduction in objective binges for all participants, four participants noted an increase in subjective binges. Examination of food records revealed that over the course of treatment, several participants began labeling the intake of small amounts of food as a binge if they ate in response to stimuli other than hunger. BES Scores. Scores on the BES decreased for all participants except one. Three participants dropped from the moderate problem range to the little or no problem range. Two participants dropped from the severe problem range to the moderate problem range. One participants score increased slightly (29 to 33). However, this participant reduced her objective binge episodes by 43%. EDE Scales. Mixed results were obtained for the subscales of the EDE. Restraint and shape concern scores improved slightly at post treatment, while still well above the range of a normal control sample. Scores on the weight concern scale increased slightly.

Ruth A. Baer, Sarah Fischer, and Debra B. Huss

However, scores on the eating concern scale improved substantially, though they remained above the normal range. EEI. Results were also mixed for scores on the EEI, which assesses beliefs that eating is reinforcing in a variety of ways. Belief that eating alleviates negative affect decreased, but was still above the normal range of the validation study control sample. A decrease of nearly one standard deviation was noted in the belief that eating leads to feeling out of control, which is consistent with the decrease in EDE eating concern scale scores. Finally, belief that eating alleviates boredom increased slightly. This may be related to the increase in subjective binges, in which participants labeled eating in response to stimuli other than hunger as a binge. It is also possible that increased mindfulness enabled participants to recognize more easily a tendency to eat when bored. KIMS. Post-treatment scores reected a moderate increase in noticing and attending to thoughts, feelings, sensations, and perceptions, and a substantial increase in acceptance of these experiences. Both scores at post-test fell above the means on these subscales for a nonclinical student sample. BDI-II. For ve participants, scores on the BDI-II fell to the minimal range. The sixth participant showed an increase in her depression score. This seemed related to several stressful personal circumstances that arose during the course of treatment. Discussion Results showed substantial improvements in symptoms, including frequency of binges and binge-related concerns. These data also provide preliminary evidence that mindfulness training led to increases in mindfulness, as clients scores on the KIMS showed a moderate increase in attention to internal experiences, and a substantial increase in nonjudgmental acceptance of these phenomena. However, a few outcomes were unexpected, including an increase in reported subjective binges over the course of treatment. As treatment progressed, examination of food records and client self-report in sessions revealed that they became steadily more able to discriminate hunger from other sensations. Thus, the increase in reported subjective binges appeared to reect increased sensitivity to internal

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states, rather than increased binge eating per se. Small increases in weight concern at post-treatment also were noted. Although therapists attempted to clarify that treatment was aimed at binge reduction rather than weight loss, many participants were obese and hoped to lose weight as a consequence of stopping binge eating. These participants may have been even more concerned about their weight when this did not occur.

GENERAL DISCUSSION A mindfulness-based approach to disordered eating raises interesting questions about which dependent variables should be expected to change with treatment. Unlike more traditional approaches, MBCT makes no attempt to change thought content or negative emotional states. Instead, it emphasizes allowing these phenomena to come and go as they are, and making adaptive choices about how to respond to their presence, rather than by binge eating. In our study, it was hypothesized that a mindful approach to thoughts and emotions would reduce functional relationships between these phenomena and binge eating, such that respondents would be able to refrain from binging even when experiencing them. Consistent with our hypothesis, frequency of binge eating was greatly reduced. However, as the intervention did not target thought content or frequency of negative emotion, it is important to examine whether these variables changed. The eating, weight, and shape concerns subscales of the EDE are helpful for this purpose. It is not surprising that eating concern showed a substantial improvement (ES = 2.9), because it assesses worries about eating patterns, which had improved markedly. However, shape and weight concerns changed only minimally (weight concern got slightly worse). These ndings suggest that after treatment, participants were better able to refrain from binge eating in spite of having continued negative thoughts and emotions about their shape and weight (which had not changed). A similar point can be made about the Eating Expectancies Inventory. A substantial improvement was noted for eating leads to feeling out of control. This is not surprising, because uncontrolled eating had been greatly reduced. However, scores for manages negative affect and alleviates boredom changed less. These ndings suggest that participants may have learned to recognize that eating does in fact alleviate negative affect and boredom (at least temporarily), but have developed the

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ability to refrain from binge eating in spite of these truths. Finally, increases in KIMS scores, especially the nonjudgmental acceptance scale, provide additional evidence that treatment effects may have been related to increased ability to adopt a mindful perspective about thoughts and emotions, rather than to changes in these phenomena. In summary, ndings of this pilot study support the theoretical discussion earlier in this paper in suggesting that mindfulness training can interrupt the usual relationships between internal experiences (thoughts, emotions) and overt behavior, without directly targeting thoughts or emotions for change. Future studies examining mindfulness and acceptance-based treatments for disordered eating could directly compare these approaches to more traditional empirically supported methods. While this study cannot address the efcacy of mindfulness-based treatment compared to other treatments, results indicate that mindfulness-based treatment is promising.

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