Mindfulness and Acceptance in the Treatment of Disordered Eating

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 briefly described. Empirical data are presented from a pilot study of mindfulness-based cognitive therapy adapted for treatment of binge eating.

Full text

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 briefly 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 ther-
apy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984), and
dialectical behavior therapy (DBT; Linehan, 1993a, b), all of which
have shown clinically significant 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.
Journal of Rational-Emotive & Cognitive-Behavior Therapy (Ó 2006)
DOI: 10.1007/s10942-005-0015-9
Ó 2006 Springer Science+Business Media, Inc.

individuals suffering from bulimia nervosa or binge eating disorder
(Garner, Rockert, Davis, & Garner, 1993; Safer, Telch, & Agras,
2001b; Telch, Agras, & Linehan, 2001; Wilfley et al., 1993). Although
many participants in these treatments show substantial improve-
ments, some do not, suggesting that additional efforts to improve
treatment efficacy are needed. Recently, several authors have sug-
gested that acceptance-based methods for treating disordered eating
merit increased attention (Wilson, 1996).
The efficacy of mindfulness-based interventions, which encourage
nonjudgmental acceptance of experience, is gaining increasing empir-
ical 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 with-
out 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 ap-
proaches to disordered eating has been investigated in only a few
studies, early results are promising. DBT, as adapted for eating dis-
orders, 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 eat-
ing (Baer, Fischer, & Huss, 2005; Heffner, Sperry, Eifert, & Detweil-
er, 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 disor-
dered eating are reviewed. We describe two theoretical models of dis-
ordered eating, and discuss how mindfulness practices may affect the
processes that initiate and maintain pathology in both of them. Next,
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

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 specified (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, dispropor-
tionate 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 exer-
cise. In both AN and BN, self-evaluation is unduly influenced 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 significant 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 significant 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 mainte-
nance of bulimia and binge eating describes a transactional chain of
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

events that begins with distorted thoughts about thinness and diet-
ing, 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 benefits of
thinness are hypothesized to lead to strict dieting. The resulting calo-
ric 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 con-
cerns 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 evi-
dence 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, defined 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 disor-
ders provides additional empirical evidence for the role of distorted
cognitions in disordered eating behavior. Response outcome expectan-
cies are beliefs that a given behavior will result in a given outcome
(Bolles, 1972; MacCorquodale & Meehl, 1953; Rotter, 1954). Expec-
tancies are formed as a result of one’s learning history, either
through direct learning experiences or through modeling by others,
and are thought to be causally linked to behavior. Outcome expectan-
cies regarding thinness include ‘‘I would be more self-reliant and
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

independent if I were thin,’’ and ‘‘I would feel more capable and confi-
dent 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 com-
plete failure of the entire diet. This thought often leads to binge eat-
ing, 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 non-
judgmental observation and acceptance of sensations, cognitions, and
emotions. Mindfulness-based approaches typically do not include tra-
ditional 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 fluctu-
ating and transient mental events, rather than factual or accurate
representations of reality. This decentered view, also known as defu-
sion in ACT, should reduce the believability of thoughts and promote
the realization that thoughts do not necessitate specific behaviors.
For example, a client may have distorted thoughts about the conse-
quences 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 reflect reality or require any particular behavior, thus
reducing the client’s 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
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

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 emo-
tional states in individuals who lack more adaptive emotion regula-
tion 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 of-
ten than those without. Second, women with BN endorse the belief
that eating alleviates distress, and coping motives are positively re-
lated to food consumption (Hohlstein et al., 1998; Jackson, Cooper,
Mintz, & Albino, 2003). Studies using daily diary methods find 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 ea-
ten 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 strong-
ly 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 defined as unwilling-
ness to experience negative feelings, sensations, or thoughts, and tak-
ing 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 mal-
adaptive and pathological behavior is the result of counterproductive
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

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 findings suggest that many cases of
disordered eating could be viewed as failed attempts to regulate aver-
sive internal experiences. Although individuals with eating disorders
may believe that eating will alleviate distress, and may feel momen-
tary 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 experi-
ential 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 tran-
sient events that do not require specific behaviors. The knowledge
and experience that emotions are fleeting 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. Line-
han (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 influence the
client to behave differently in response to the situation that origi-
nally caused the anger. That is, instead of taking steps to obtain fair-
er 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, accep-
tance 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
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

emotional states. If a client’s 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 acceptance-
related approaches to disordered eating have been introduced, and
empirical support for their efficacy is increasing steadily. They
include DBT, MBCT, ACT, and MB-EAT.
Dialectical behavior therapy (DBT; Linehan, 1993a, b) was devel-
oped 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 func-
tions to reduce aversive emotional states, and that by diverting
attention from negative affect, binge eating temporarily reduces dis-
tress 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, with-
out 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 adapta-
tion 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
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

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 inter-
vention includes several mindfulness and acceptance-based strategies
for working with fat-related thoughts, images, and fears. For exam-
ple, the thought parade is a mindfulness exercise in which the partic-
ipant 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 ‘‘I’m 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. Fat-
related thoughts are conceptualized as passengers on the bus, who
demand that she change direction and drive the bus ‘‘down the anor-
exia 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
clarification of the patient’s 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.
Efficacy of MB-EAT has been supported in an uncontrolled trial
(Kristeller & Hallett, 1999) and in a recent controlled trial
(Kristeller, unpublished data).
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

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). Addi-
tional 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 influ-
ence 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 dif-
ference between MBCT and most other empirically supported treat-
ments for eating problems, which include a higher number of change
strategies. In accordance with the theoretical models discussed ear-
lier, 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 flyers 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 com-
plete 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
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

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 Dis-
order 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 34-
item Likert-type inventory with five 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: obser-
vation 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, briefly described the circum-
stances, 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 post-
treatment 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 objec-
tive binge episodes, having engaged in three to five 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 symp-
toms of bulimia and had also been previously diagnosed with alcohol
abuse or dependence. One participant had a diagnosis of Bipolar II
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

disorder. Six of the 10 women completed treatment and post-treat-
ment assessments. The remaining clients attended five or more ses-
sions, 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 Master’s-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 Master’s level therapist agreed to practice the med-
itation 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 compari-
son to a 10-session cognitive-behavioral protocol in future research.
At points where the MBCT manual describes material specific 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 numer-
ous parts of the body, and sensations are observed nonjudgmentally.
If thoughts and emotions arise, these are noted briefly 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 difficulty related to binging, and observing
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

associated sensations and emotions without trying to change or elimi-
nate 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 final few weeks.
Several sessions included cognitive therapy exercises that teach an
accepting, nonjudgmental, and non-reactive attitude toward cogni-
tions. Relationships between situations, thoughts, and emotions were
discussed, with emphasis on the concepts that ‘‘thoughts are not
facts,’’ and that ongoing moods can influence 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 mas-
tery 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, empha-
sizing 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 instrument’s normal control sample, thus quantifying the mag-
nitude of change in standard deviation units. Positive effect sizes
indicate change in the therapeutic direction.
Objective Binges. According to Fairburn and Cooper (1993), an objec-
tive binge includes an amount of food larger than most people would
eat in a discrete time period. A subjective binge is seen by the partic-
ipant 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.
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

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
participant’s score increased slightly (29 to 33). However, this partici-
pant 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.
Table 1
Pre- and Post-treatment Scores and Effect Sizes
Measure Pre Post Effect size
*
Objective binges per month (EDE) 15.67 4.0 N/A
Subjective binges per month .68 4.0 N/A
Eating Disorder Examination subscales
Restraint 2.50 2.10 .42
eating concern 2.98 1.77 2.90
weight concern 3.13 3.34 ).28
shape concern 3.70 3.35 .41
Binge Eating Scale 25.80 18.40 .88
Eating Expectancies Inventory
manages negative affect 5.25 4.64 .61
leads to feeling out of control 5.40 4.40 .96
alleviates boredom 5.45 5.85 ).26
Kentucky Inventory of Mindfulness Skills
Observation 71.33 81.00 .72
nonjudgmental acceptance 35.67 49.00 1.58
Beck Depression Inventory 12.20 9.20 .30
*
magnitude of change calculated in standard deviation units of the instrument’s normative sam-
ple, positive effect size indicates change in the therapeutic direction.
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

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 allevi-
ates 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 reflected a moderate increase in
noticing and attending to thoughts, feelings, sensations, and percep-
tions, 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 five 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 sub-
stantial 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 treat-
ment 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 reflect increased sensitivity to internal
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

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 interest-
ing 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 hypothe-
sis, 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. How-
ever, shape and weight concerns changed only minimally (weight
concern got slightly worse). These findings suggest that after treat-
ment, 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 ‘‘allevi-
ates boredom’’ changed less. These findings suggest that participants
may have learned to recognize that eating does in fact alleviate nega-
tive affect and boredom (at least temporarily), but have developed the
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

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, findings of this pilot study support the theoretical dis-
cussion 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 mindful-
ness and acceptance-based treatments for disordered eating could
directly compare these approaches to more traditional empirically
supported methods. While this study cannot address the efficacy of
mindfulness-based treatment compared to other treatments, results
indicate that mindfulness-based treatment is promising.
REFERENCES
Agras, W. S., & Telch, C. F. (1998). The effects of caloric deprivation
andnegative affect on binge eating in obese binge-eating disordered
women. Behavior Therapy, 29, 491–503.
American Psychiatric Association. (2000). Diagnostic and statistical manual
of mental disorders (4th ed., text revision) (DSM-IV-TR). Washington, DC:
Author.
Apple, R. A., & Agras, W. S. (1997). Overcoming eating disorders: A cognitive-
behavioral treatment for bulimia nervosa and binge-eating disorder. New
York: The Psychological Corporation.
Baer, R. A. (2003). Mindfulness training as a clinical intervention: A
conceptual and empirical review. Clinical Psychology Science and
Practice, 10, 125–143.
Baer, R. A., Fischer, S., & Huss, D. B. (2005). Mindfulness-based cognitive
therapy applied to binge eating: A case study. Cognitive and Behavioral
Practice, 12, 351–358.
Baer R. A., Smith G. T., Allen K. B., (2004). Assessment of mindfulness by
self-report: The Kentucky Inventory of Mindfulness Skills Assessment
191–206.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II
Manual. San Antonio, TX: The Psychological Corporation.
Blackledge, T. J., & Hayes, S. C. (2001). Emotion regulation in acceptance and
commitment therapy. Journal of Clinical Psychology: In session: Psycho-
therapy in Practice, 57, 243–255.
Bolles, R. C. (1972). Reinforcement, expectancy, and learning. Psychological
Review, 79, 394–409.
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

Clark, D. M., Ball, S., & Pape, D. (1991). An experimental investigation of
thought suppression. Behaviour Research and Therapy, 29, 253–257.
Crowther, J. H., Snaftner, J., Bonifazi, D. Z., & Shepherd, K. L. (2001). The
role of daily hassles in binge eating. International Journal of Eating
Disorders, 29, 449–454.
Fairburn, C. G. & Cooper, Z. (1993). The eating disorder examination (12th
ed.). In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature,
assessment, and treatment (pp. 317–332).
Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral
therapy for binge eating and bulimia nervosa: A comprehensive treatment
manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature,
assessment, and treatment, New York: Guilford Press.
Fischer, S., Smith, G. T., & Anderson, K. G. (2003). Clarifying the role of
impulsivity in bulimia nervosa. International Journal of Eating Disor-
ders, 33, 406–411.
Garner, D. M., Rockert, W., Davis, R., & Garner, M. (1993). Comparison of
cognitive-behavioral and supportive-expressive therapy for buolimia
nervosa. American Journal of Psychiatry, 150, 37–46.
Gormally, J., Black, S., Daston, S., & Rardin, D. (1982). The assessment of
binge eating severity among obese persons. Addictive Behaviors, 7, 47–55.
Gross, J. J. (2002). Emotion regulation: Affective, cognitive, and social
consequences. Psychophysiology, 39, 281–291.
Gross, J. J., & John, O. P. (2003). Individual differences in two emotion
regulation processes: Implications for affect, relationships, and well-
being. Journal of Personality and Social Psychology, 85, 348–362.
Halliwell, E., & Dittmar, H. (2004). Does size matter? The impact of model’s
body size on women’s body-focused anxiety and advertising effectiveness.
Journal of Social and Clinical Psychology, 23, 104–122.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and
commitment therapy: An experiential approach to behavior change. NY:
Guilford.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K.
(1996). Emotional avoidance and behavioral disorders: A functional
dimensional approach to diagnosis and treatment. Journal of Consulting
and Clinical Psychology, 64, 1152–1168.
Heatherton, T. F., & Baumeister, R. F. (1991). Binge eating as escape from
self-awareness. Psychological Bulletin, 110, 86–108.
Heffner, M., Sperry, J., Eifert, G. H., & Detweiler, M. (2002). Acceptance and
commitment therapy in the treatment of an adolescent female with
anorexia nervosa: A case example. Cognitive and Behavioral Practice, 9,
232–236.
Heffner, M., & Eifert, G. H. (2004). The anorexia workbook: How to accept
yourself, heal your suffering, and reclaim your life. Oakland, CA: New
Harbinger.
Herzog, D. B., Keller, M. B., Lovari, P. W., & Sacks, N. R. (1991). The course
and outcome of bulimia nervosa. Journal of Clinical Psychiatry, 52(Suppl.
10), 4–8.
Journal of Rational-Emotive & Cognitive-Behaviour Therapy

Hohlstein, L. A., Smith, G. T., & Atlas, J. G. (1998). An application of
expectancy theory to eating disorder: Development and validation of
measures of eating and dieting expectancies. Psychological Assessment,
10, 49–58.
Jackson, B., Cooper, M. L., Mintz, L., & Albino, A. (2003). Motivations to eat:
Scale development and validation. Journal of Research in Personality, 37,
297–318.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for
chronic pain patients based on the practice of mindfulness meditation:
Theoretical considerations and preliminary results. General Hospital
Psychiatry, 4, 33–47.
Kabat-Zinn J. (1990). Full catastrophe living: Using the wisdom of your body
and mind to face stress, pain, and illness. New York: Delacorte.
King, M. B. (1991). The natural history of eating pathology in attenders to
primary care. International Journal of Eating Disorders, 10, 379–387.
Klerman, G. L, Weissman, M. M., rounsaville, B. J., & Chevron, E. S. (1984).
Interpersonal psychotherapy of depression. New York: Basic Books.
Kristeller, J. L., & Hallett, C. B. (1999). An exploratory study of a meditation-
based intervention for binge eating disorder. Journal of Health
Psychology, 4, 357–363.
Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline person-
ality disorder. New York: Guilford Press.
Linehan, M. M. (1993b). Skills training manual for treating borderline
personality disorder. New York: Guilford Press.
Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for
depression: Replication and exploration of differential relapse prevention
effects. Journal of Consulting and Clinical Psychology, 72, 31–40.
MacCorquodale, K., & Meehl, P. E. (1953). Preliminary suggestions as to the
formulation of expectancy theory. Psychological Review, 60, 55–63.
Millar, H. R. (1998). New eating disorder service. Psychiatric Bulletin, 22,
751–754.
Rotter, J. B. (1954). Social learning and clinical psychology. Englewood Cliffs,
NJ: Prentice Hall.
Safer, D. L., Telch, C. F., & Agras, W. S. (2001a). Dialectical behavior therapy
adapted for bulimia: A case report. International Journal of Eating
Disorders, 30, 101–106.
Safer, D. L., Telch, C. F., & Agras, W. S. (2001b). Dialectical behavior therapy
for bulimia nervosa. American Journal of Psychiatry, 158, 632–634.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based
cognitive therapy for depression: A new approach to preventing relapse.
New York: Guilford Press.
Smith, G. T., Simmons, J. R., Annus, A. M., & Hill, K. K. (2005). Thinness and
eating expectancies predict subsequent binge eating and purging behavior
among adolescent girls. Manuscript submitted for publication.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-
analytic review. Psychological Bulletin, 128, 825–848.
Ruth A. Baer, Sarah Fischer, and Debra B. Huss

Stice, E., & Shaw, H. E. (2002). Role of body dissatisfaction in the onset and
maintenance of eating pathology: A synthesis of research findings.
Journal of Psychosomatic Research, 53, 985–993.
Striegel-Moore, R. H., Dohm, F. A., Solomon, E. E., Fairburn, C. G., Pike, K.
M., & Wilfley, D. E. (2000). Subthreshold binge eating disorder. Interna-
tional Journal of Eating Disorders, 27, 270–278.
Stunkard, A. J. (1993). A history of binge eating. In C. G. Fairburn & G. T.
Wilson (Eds.), Binge eating: Nature, assessment, and treatment,New
York: Guilford Press.
Teasdale, J. D., Williams, J. M. G., Soulsby, J. M., Segal, Z. V., Ridgeway, V.
A., & Lau, M. A. (2000). Prevention of relapse/recurrence in major
depression by mindfulness-based cognitive therapy. Journal of Consult-
ing and Clinical Psychology, 68, 615–623.
Telch, C. F., Agras, W. S., & Linehan, M. M. (2000). Group dialectical behavior
therapy for binge-eating disorder: A preliminary uncontrolled trial.
Behavior Therapy, 31, 569–582.
Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior
therapy for binge eating disorder. Journal of Consulting and Clinical
Psychology, 69, 1061–1065.
Telch, C. F., Pratt, E. M., & Niego, S. H. (1998). Obese women with binge
eating disorder define the term binge. International Journal of Eating
Disorders, 24, 313–317.
Thompson, J. K., van den Berg, P., Roehrig, M., Guarda, A. S., & Hienberg, L.
J. (2004). The Sociocultural Attitudes Towards Appearance Scale-3
(SATAQ-3): Development and validation. International Journal of Eating
Disorders, 35, 293–304.
Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole,
A. G., Sifford, L., & Raeburn, S. D. (1993). Group cognitive-behavioral
therapy and group interpersonal psychotherapy for the nonpurging
bulimic individual: A controlled comparison. Journal of Consulting and
Clinical Psychology, 61, 296–305.
Wilson, G. T. (1996). Acceptance and change in the treatment of eating
disorders and obesity. Behavior Therapy, 27, 417–439.
Wiser, S., & Telch, C. F. (1999). Dialectical behavior therapy for binge eating
disorder. Journal of Clinical Psychology, 55, 755–768.
Journal of Rational-Emotive & Cognitive-Behaviour Therapy