Written by: Pam Siegel MPH, MFT and Lea Roussos, MS, MFT.
Mindfulness has been around for centuries but is finding a new level of credibility, particularly in the treatment of eating disorders. We have found success in applying mindfulness practice in a group setting for eating disordered clients. This article provides a brief introduction to mindfulness, an explanation of both formal and informal mindfulness practice, a discussion of the application of such practice in group sessions, and insight into the success of such sessions of individuals with eating disorders.
An Introduction to Mindfulness
While the concept of mindfulness is rather simple, its benefits are powerful and far-reaching. Mindfulness has been used in both monastic and secular settings for over 2,500 years. The term “mindfulness” is an English translation of the Pali word “sati.” Pali was the original language used in Buddhism centuries ago. Mindfulness is the core teaching of this tradition; “sati” connotes awareness, attention, and remembering. Mindfulness is paying attention to what is happening in the present moment. (Germer, Siegel, and Fulton, 2005)
When used in a therapeutic setting, the definition of mindfulness includes the aspect of being non-judgmental. Jon Kabat-Zinn, a renowned meditation teacher and researcher, defines mindfulness as “the awareness that emerges through the paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment to moment.”(Kabat-Zinn, 1990) Basically, mindfulness is a particular way of looking deeply inside to promote understanding and healing with an acceptance of “what is.” As Carl Rogers observed years ago, “the curious paradox is that when I accept myself just as I am, then I can change.”(Schwartz, 2011)
In recent years, mindfulness has proliferated into the field of psychotherapy and is gaining popularity in areas such as education and business. Studies on the neurobiology of the brain show that by practicing “mindfulness” we actually change our behaviors right down to the synaptic level, enabling us to be aware of our mental processes without getting swept up in them. When we go inside and are “mindful” of our feelings we can reduce their intensity—“to name them we tame them.” Dan Siegel, one of the foremost innovators in the field of brain science, has spent 25 years of clinical work in this field. He concludes that by focusing our attention inward to the workings of our mind, we can “get off the autopilot of ingrained behaviors and habitual responses and move beyond them.” (Siegel, 2010) His work and those of other researchers have given a new level of credibility to the practice of mindfulness meditation that is now used to treat a variety of disorders including eating disorders, depression, anxiety, and attention deficient disorder (ADD).
Mindfulness in Practice
Mindfulness can be learned. There are two types of mindfulness training: formal and informal practice. Formal mindfulness practice involves setting aside a specific amount of time, usually thirty minutes or longer, to consciously “go inside” and be aware of what is sensed or felt in the mind and/or body, using the breath as an anchor. This practice can include a sitting/walking meditation, body scan (systematic inward scan of body parts), or yoga session. Informal mindfulness practice involves finding brief moments in everyday life to pay attention to events and surroundings in the present. Instead of multi-tasking and spending extended periods on automatic pilot, a person practicing informal mindfulness would focus on paying attention to one thing at one time. For example, while walking outside or listening to music, one would intentionally focus on that activity without distraction.
Practicing mindfulness, both formally and informally, can be especially helpful for individuals with eating disorders. Mindfulness provides a way to cope with the obsessions, shame, and anxiety that accompany individuals with eating disorders, many of whom have a difficult time feeling and/or managing their feelings. Food and body preoccupation can distract from accessing true emotions. Mindfulness helps create a tolerance and comfort for those feelings. In 1993 Marsha Linehan developed a “dialectical behavioral training” (DBT) program, of which mindfulness is an integral part, to help borderline personality clients who have difficulty regulating their emotions, similar to clients with eating disorders. She found mindfulness practice to “increase self-awareness, increase self acceptance, reduce reactivity to thoughts and emotions, improve ability to make adaptive choices, and improve capability to respond to aversive experience.” (Linehan, 1993) National Institute of Health funded studies by Jean Kristeller show how mindfulness meditation helps individuals with Binge Eating Disorder (BED) reduce binges and improve self -esteem and body image. (Kristellar, 2003 and 2006) Informal and formal mindfulness practice also helps individuals with eating disorders slow down and look inside to see what really feeds their “hunger.”
The Benefits of Group Process
The benefits of group process for eating disordered clients is well supported.(Costin,1996, 2007) According to Irving Yalom, a group can offer “hope, universality, altruism, group cohesion, and interpersonal learning.” (Yalom, 1995) Eating disordered clients often display certain characteristics that make them particularly well suited for group treatment such as feelings of interpersonal distrust, low self-esteem, ineffectiveness, social isolation, and distorted thinking. These “symptoms” are challenged by the interpersonal nature of group process and are vital in helping eating disorder clients in their recovery.
A therapist can provide support both directly and indirectly within a group setting. Direct support is given by personal engagement, empathic listening, and understanding while indirect support is provided by building a cohesive group in a safe environment. However, it is the interpersonal interactions within groups that are the most powerful agents of change. (Yalom, 1995)
Our Group Experiences
As group facilitators/therapists, we created a “mindfulness” group for clients with eating disorders for personal and professional reasons. We have experience with in-patient and outpatient eating disorder treatment centers and have seen first hand the strong benefit of groups in these environments. Also, we have both undergone extensive mindfulness training ourselves (taught by Jerome Front) and practice regularly through yoga and other types of mindfulness meditations. We have seen how informal and formal mindfulness practice has changed our own lives, as well as the lives of our clients. We both have seen a difference is our ability to “”hold” feelings as they ebb and flow in our personal and professional lives. We are more likely to “respond rather than react” to our family members and generally feel more calm and centered. Mindfulness meditation has certainly affected our ability to be present with our clients and friends and to be more comfortable with silence in sessions. Having our own mindfulness practices enables us to be more authentic with the group as we teach and share our own experiences.
This then is the genesis and reason why we wrote this article; not as a scientific study, but rather as an overview of our experience using mindfulness practices in a group setting for clients with eating disorders. We noticed positive changes with the members who regularly attended our group sessions and practiced the mindfulness skills. Our experience is consistent with the literature on the effects of mindfulness. (Germer, Siegel, and Fulton, 2005, Katat-Zinn, 199O) Specifically, many group members changed their food behaviors (reduced bingeing/purging with Bulimia or BED and increased food intake with Anorexia) and improved their self-esteem, body image, and social relationships. They also were able to handle their emotions without going to their habitual reactive behaviors. The following stories of four group members exemplify the success of this process. Lisa has been struggling with Binge Eating Disorder (BED). After eight months in the group she is now feeling good enough about herself and her recovery to start graduate school in psychology; Jessica, a writer who has been struggling with Anorexia, is now at a new job and doing well. She has stopped isolating and is even in a new intimate relationship; Marissa, a teacher, is now leading a student trip to South America, something she never dreamed she could do because of her severe bulimia. She says she is now “present” in her life rather than being caught up in thinking about ED; and Marni was able to go on a vacation with her husband and feel comfortable in her bathing suit. While she and most of the members still struggle with their body image (it is the hardest part of recovery and the usually the last area to get better) at least she was able to get into a bathing suit and have moments of fun.
Our eating disorder group has met consistently for over two years, emphasizing mindfulness both through meditation and psycho-education. The group, led by both of us, meets once a week for 90 minutes. The participation of two therapists is both a luxury and a necessity. We complement and support each other, adding greatly to the therapeutic power of the group. We work in different but complementary ways to enhance group cohesion and openness. For example, Pam being an ex-teacher, at times uses a more instructional approach (using biblio- therapy or psycho-education) while Lea may help the members go inward and be more mindful of their feeling states.
A typical group session begins with the introduction or review of a mindfulness skill to help clients enhance their mindfulness work. Usually one therapist presents the skill, but we recently encouraged a few group members to teach the others. This process has proven to be an excellent way for group members to learn from each other, which can be more effective than learning from the therapist. When a member sees how another uses a tool successfully, she often copies the behavior. A group member was having a particularly difficult time handling the ups and downs of her emotions and began using journaling extensively as a way to center herself and become more “mindful” of her inner world. Writing increased her ability to identify, feel, and tolerate her moment- to- moment experience. Journaling became a ‘meditation’ for her as it calmed her and helped her understand herself. She enthusiastically shared her experiences with the other members and little by little, almost all of the group members began to use this tool.
We use a variety of different mindful skills in our group sessions including some techniques from Marsha Linehan’s Dialectical Behavioral Therapy workbook such as “wise mind’ or “riding the wave.” (Linenhan, 1993 and Moonshine, 2008)
Each week, we review the skill learned the previous week and then present a new one. The next 20 minutes is a group meditation that is led by the therapists or by playing a meditation CD (such as one from Jon Kabat Zinn, Jerome Front, or Diana Winston). Most often the group will do a sitting meditation, but occasionally we do body scan meditations as well.
After the meditation, we take a few minutes for members to process their immediate reactions to the meditation, including what they notice during this process. For example, we often hear that a member feels like she has “monkey mind,” a mind jumping all over and not able to settle and concentrate on the breathing. We reassure them that this is normal and that even long time meditators have this occur at times. We stress the importance of gently bringing their attention back to their breath without judgment.
In the last part of the session, the group members discuss their week with their eating disorder (ED) and what skills, if any, they were able to access to help them deal with their issues. Other members are invited to offer feedback (without giving advice) based on their own experience. One example of this occurred recently when one member, Jan, spoke about her difficulty finding her voice in dealing with her parent’s negative comments and lack of boundaries. Another member, Marni, had similar issues and was able to relate how she handled her own parents. “Before coming to this group, I had no way to handle my emotions and I did not have a voice. I would let my parents say terrible things to me and then act out with ED to calm myself. This group has taught me to be mindful and “ride the wave” of my emotions, knowing that they will ebb and flow without having to go to ED behaviors.” This interaction was beneficial for all members to hear.
The cohesion of this group has been quite strong and we see how effective it has been in preventing group members from relapsing (going back into their eating disorder behaviors such as restricting or binging/purging) Group members text each other during the week and, at times, meet for meals for additional support. We continuously encourage the members to reach out to each other whenever they feel urges to act out their eating disorder behaviors. Isolation is a key problem with eating disordered clients, and the group forces them to become more social. One member has been struggling with being alone with ED and slowly we are seeing her begin to participate more. Recently she expressed that she was going to a yoga class with another member in the group. This was a huge step for her.
Group members must meet specific guidelines to qualify for the group. First, they must be in individual therapy, as the group is not a substitute for individual treatment. Group work can bring up a variety of difficult issues, particularly with a mixed group of eating disordered clients (both anorexic and bulimic clients in the group) and it is imperative that the members have a safe place to process such issues with their therapist individually. Often clients are triggered by what they see or hear from the other clients. For example, when members see others relapsing it can cause anxiety and/or hopelessness in other group members. Other clients may be “triggered” by the size of the other group members, whether they are smaller or larger than themselves. Again, they need to talk about these issues with their individual therapist.
Second, the members must commit to maintaining an environment that feels safe for group members to be open and share their struggles. Group confidentiality and non-judgmental feedback to other group members is emphasized on a regular basis. Third, group members must also commit to attend the group sessions consistently. Finally, they must be able to pay a nominal fee for the sessions. We initially screen each member carefully to discern if they meet these qualifications and continue to do so as time goes on.
Our mindfulness support group has been an amazing journey for us, both personally and professionally. The impact of mindfulness and the power of the group have been dramatic and this entire experience has provided enormous gratification for us personally. There have been times of crisis when members have cried or relapsed, and other times when we have shared laughter and joy. We have learned from the group members as much as we hope they have learned from us. As our own mindfulness has grown through meditation practice and professional training, we have seen ourselves become more empathic, patient, and non-judgmental. These changes have clearly impacted the group members. We are challenged at each session, constantly trying new skills and evaluating the outcomes but feel committed to continue using mindfulness as our primary tool to treat eating disorders.
One member, who has been in the group since its beginning and who is training to become a therapist, is now ready to leave. Her parting words sum up the impact this mindfulness group has had on her recovery. “Learning about and practicing mindfulness has changed my life. I am now behavior free for 18 months. I feel confident in my ability to use the tools to remain free from ED; I now feel empowered and strong enough to handle my emotions in a more positive way. The group has been an amazing source of support and encouragement. I am so grateful for this amazing experience and I want to now pass this on to my own clients.”
Pam Siegel MPH, MFT.
Lea Roussos, MS, MFT.
1460 7th St., Ste. 206
Santa Monica, 90401
Costin, C. (1996) The Eating Disorder Sourcebook. Los Angeles: Lowell House
Costin, C. (2007) 100 Questions and Answers about Eating Disorders. Canada:Jones and Bartlett Publishers, Inc.
Germer, C., Siegel, R., and Fulton, P. (2005) Mindfulness and Psychotherapy. New York: Guilford Press.
Kabat-Zinn, J. (1990) Full Catastrophe Living. New York: Bantam Dell
Kristellar, J. (2003) Mindfulness, Wisdom, and Eating: Applying a Multi-Domain Model of Meditation Effects. Journal of Constructivism in Human Sciences Vol 8 (2) 107-118
Linenhan, M. Skills Training Manual for Treating Personality Disorder. New York: Guilford Press
Siegel, D. (2010) Mindsight-The New Science of Personal Transformation. New York: Random House
Siegel, D. (2010) The Mindful Therapist. New York: W.W. Norton and Co., Inc.
Schwartz, R. (2011) When Meditation Isn’t Enough. The Psychotherapy Networker.September-October 2011 35-38
Yalom, I. (1995) The Theory and Practice of Group Psychotherapy. New York: BasicBooks.