Unlike other addictions and life threatening illnesses, eating disorders live and breath in silence. I worked as a staff therapist at one of San Francisco’s few inpatient eating disorder treatment centers with a dynamic team of nurses, nutritionists, and therapists. Many of the anorexic and bulimic women who came there for treatment were in dangerously poor health. Our task was to stabilize them physically, mentally, and emotionally before discharge.
I had never worked with eating disorder patients at this level of severity, but was hired nonetheless to facilitate interpersonal process groups, provide Dialectical Behavior Therapy skills training, and perform individual and family therapy with the patients. For me, it was an opportunity to learn and grow. I had no idea that it would also present another occasion to put my spiritual rubber to the road.
The dharma is so amazingly timeless and versatile. Within the teachings and practices are bountiful skillful means to benefit sentient beings. Mindfulness and awareness practices are central to both therapeutic modalities used in the clinical treatment of eating disorders; Dialectical Behavior Therapy (DBT) and Somatic Experiencing (SE). DBT works with mindfulness of mind, mindfulness of thoughts, and mindfulness of feelings. SE focuses on mindfulness of body. It is through the teaching and application of these modalities that I have learned to appreciate the dharma in a whole new way.
I began all our process groups at the treatment center with meditation. We practiced mindful breathing (counting breaths from one to ten, focusing on the sensation of breath passing in and out of the nose, and focusing on the pause in between inhalation and exhalation). We then worked on the mindfulness skills of noticing (noticing sounds, noticing with vision, noticing thoughts, noticing emotions, and noticing physical sensations) and labeling (using thoughts to describe our experience, free of interpretations, judgments, and assumptions).
Mindfulness skills are the foundation of DBT because without increasing awareness in each moment, it’s hard to make better choices and change our behavior. Mindfulness and awareness together make it easier to learn the other DBT skills, such as distress tolerance and interpersonal effective skills. Mindfulness helped the patients break free of eating disorder (ED) mind by bringing them back to the present moment. Other mindfulness practices that are part of the DBT curriculum include; engaging (finding activities that bring a sense of effortlessness and ease), one-pointedness (doing one thing at a time), equanimity (being aware without judgement), and acting effectively (using all the skills together along with knowing what we want).
In individual and groups sessions, patients discovered and explored wise mind, the DBT term for the ability to think rationally in combination with emotions. Patients learned to have contact with their emotions, without being dominated by them. They learned to think logically without losing touch with their feelings and thereby cutting off access to important information. Breathing mindfully, ask yourself, “What are my emotions telling me?” What is my reason telling me? What is my wise mind telling me? Wait patiently until you get an answer.
Many of the patients whom I’ve treated have endured unbearable situations that remain unprocessed. When experiences are scary and overwhelming or we don’t believe ourselves capable of surviving, we can get frozen in time. Along with fight or flight, the immobility response is a primitive instinctual method to survive a life threatening event. Animals come into frozen states and move out of them as needed, but human beings become confused and frozen. Anorexic patients are totally shut down and unable to take anything in from the environment. Bulimic patients express the two extremes of taking in too much and then needing to purge and get rid of it before it has been processed. Both are strategies to manage the feelings associated with events in the past.
When you eat, you take in food and digest it. Your body absorbs what it needs to be healthy and eliminates what it perceives as waste. This taking in, sorting through, and letting go is innate and natural. The same is true for how we experience life and all of our relationships. Somatic Experiencing mirrors the fluid adaptation responses in an attempt to unfreeze the nervous system and body-mind connection. If the restorative process (running away, screaming, getting help, etc) is inhibited the effects of the trauma become fixated and expressed by the body. SE is similar to the shamanic art of calling the subtle body back into the physical body. There is a series of exercises and practices that help patients learn to feel physical sensations and safely process events from the past. Patients also learn to identify pleasurable experiences and pleasant feelings in the body as they learn to sense themselves from the inside out.
Emotional regulation skills are how we practice mindfulness of feelings. We work with anger, fear, guilt, joy, love, sadness, and shame and identify the physical component when we feel those emotions versus other sensations like feelings of hunger and fullness. Mindfulness of the sensations help us know when we’re feeling strong emotions and therefore likely to act out of emotion mind. The patients practice mindfully scanning their bodies to identify the physiological cues for hunger, thirst, fatigue, and tension. This is especially important for people with eating disorders who don’t register or accept their basic human needs. Mindfulness of feelings practice includes; noticing the emotions (what they feel like without judgement), labeling the emotions (putting words to the experience), and engaging the emotions (accepting the experience and tolerating it). Tolerating distress is another set of skills that we practice as the patients struggle with coming back into their bodies. These include learning how to positively distract yourself, soothe yourself, relax your body, stay present in the moment, and practice acceptance. If there is nothing you can do about it, then why get upset? Pain without acceptance is suffering. Pain with acceptance is just pain.
There is so much to be said about the etiology and treatment of eating disorders. This is merely a personal reflection about the benefits of mindfulness practice in this arena. All the meals served at our center are mindful meals. When was the last time you truly had a mindful meal? Here is how to do it:
How to Eat a Mindful Meal
1: Clear the table of any clutter and set a clean and uplifted place to sit down and have your meal. Turn off all electronic devices and remove anything potentially distracting in the environment.
2: Prepare, plate, and portion your food before sitting down.
3: When you sit down, take a few deep breaths. Relax and make yourself comfortable in your chair. Gently tense and release your muscles to let go of any tension. You want to slow down the eating process so that you can experience all the different aspects of it. Bring your awareness to each of your physical senses to practice eating moment by moment.
4: Notice how the food looks on the plate (shape, color, texture, etc.).
6: Smell the food before you start eating.
7: Taste each bite, noticing all the varieties of taste as the food lands on your tongue (salty, sweet, bitter, pungent, etc.). Experience each bite from start to finish. As with any awareness practice, when you get lost in the mind’s endless chatter, “I like this. I don’t like that,” put your fork down and come back to your breath. Try to experience the pleasure of eating.
8: Notice the sounds around you as well as the sounds of eating (chewing, crunching, slurping, swallowing, etc.).
9: Bring your awareness to your body. Notice how you are sitting in your chair. Notice how you take your bites. Scan your body. Notice feelings of fullness and satiety. How do you know when you’ve had enough?
11: When you are done with your meal, don’t rush off to do something else. Sit quietly to allow your body and mind to process the experience of eating. Sip some tea. Let your body digest the meal. Notice and appreciate how you feel from the inside out.