The Impact of Mindfulness and Group Process on Eating Disorder
Recovery
by Pam Siegel MA, LMFT and Lea Roussos MA, MIM, LMFT
Copyright 2012 - Pam Siegel and Lea Roussos
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.8 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.”12 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.”