Mindful Eating from the Dialectical Perspective

Research and Application

Angela Klein

• Editorial: Routledge
• Año: 2016
• ISBN:
  9781317424994
• Edición: 1
• Categoría: Psychology
• Categoría: History & Theory in Psychology

Mindful Eating from the Dialectical Perspective is both a research reference and exhaustive guide to implementing a practice of mindful eating grounded in dialectical behavior therapy. This informative and timely new resource balances a presentation of empirical data with thorough and engaging instruction for hands-on application that features an innovative forbidden foods hierarchy construction. This invaluable guide makes the empirically supported approach accessible for therapists and anyone struggling with patterns of unbalanced eating.

1
The Open Table

All too often food is the target of judgment. It is, in perhaps its most basic definition, nourishment required to sustain life, and yet so often in modern times making decisions about food can feel like navigating a minefield. Of course, it makes sense that we are hardwired to evaluate what is “good” or “bad” to eat when it comes to deciphering what is edible and inedible. This would help us survive, for example, guiding us to nutritive options and protecting us from poisonous or spoiled intake. However, in modern times, food-related judgment is rarely about such imminently critical determinations. Instead, we often judge whether or not to eat certain foods based on our judgment of how they will impact our long-term health and mortality. More proximally, we make decisions based on our judgment of how they will impact our weight and appearance.

When I was growing up the devil was fat and anything low fat was heralded as the path to health and weight loss, with thinness revered as the symbolic embodiment of health and attractiveness. Consequently, carbohydrates, such as pasta, were considered a mainstay in dieting and items branded reduced fat or low fat were “safe.” Margarine was certainly better than butter, and egg yolks were definitely off limits—egg whites only please! Then the tide turned with the Atkins craze, claiming that carbs were actually the problem and limitless quantities of bacon were much better. Somehow I could never really make the shift to that perspective. Nowadays I find myself being assaulted with more nuanced messages about the critical importance of high protein and organic, natural foods, with a mounting tide against the horrors of gluten, sugar, dairy, processed foods, and genetically modified organisms (GMOs).

All of the rules about what one should and should not eat can be paralyzing and leave consumers staring blankly at the wall of products in the grocery store aisle, unable to process the massive array of options, each calling for analysis to determine whether it passes the tests of acceptability. Even choosing where to shop can be daunting. Retailers heralded as organic and natural can be intimidating in their higher prices, again challenging more mainstream shoppers to divine the best choices within their budget. Deciphering nutrition labeling can be another rather disheartening quest. Of course, navigating this web of rules extends beyond the grocery store, to the many settings in which we eat, from myriad menus—extensive café boards offering just the right vehicles for responsible or indulgent caffeinating; hardbound restaurant menus that look more like novelettes, sometimes even illustrated; food truck line-ups; fast food displays with scratchy voices from a speaker taking our order—to potlucks at work, parties and gatherings, holiday feasts, and our own kitchen table.

Judgments about food can serve as rules. Rules provide a shorthand strategy for making decisions across situations more efficiently. For example, if one has a rule that gluten is forbidden, this quickly eliminates a number of items on most menus, narrowing down the choices to what is gluten-free. Similarly, if one has a rule that dairy is forbidden, this quite rapidly diminishes the options at any standard ice cream parlor. Basing decisions on such rules speeds up cognitive processing. This serves a purpose, since we usually have many other demands on our time beyond food and eating. However, when we use rules to make decisions, this takes us out of the present moment and the specific, unique context of that moment and, when it comes to eating especially, it can backfire.

On the Continuum: Restriction and Binge Eating

Research has suggested that there is a continuum of eating, ranging from balanced, unrestrained eating at one end to eating disorders at the other end (Butow, Beumont, & Touyz, 1993). The boundaries between pathology on this continuum are not necessarily entirely clear. At its most extreme, disordered eating can be categorized into anorexia nervosa (AN) and bulimia nervosa (BN), although the line between these disorders is not always straightforward. For example, restriction, binge eating, and purging, such as self-induced vomiting, diuretic and laxative abuse, and excessive exercise, can characterize both AN (binge/purge subtype) and BN. The American Psychiatric Association (APA) blurred the lines even further in 2013 by removing the classic distinguishing AN characteristics of emaciation (weight below certain thresholds, such as a body mass index of 17.5) and amenorrhea (the cessation of menses for at least three months) from the diagnostic criteria for AN. Furthermore, crossover between diagnoses is relatively common (e.g., Eddy et al., 2008; Peterson et al., 2011) and empirically derived classifications include alternative variants not necessarily captured in the current APA diagnostic system (e.g., Cain, Epler, Steinley, & Sher, 2012; Dechartes et al., 2011; Peterson et al., 2011; Swanson et al., 2014; Wildes, Forbush, & Markon, 2013; for a summary see Wonderlich, Joiner, Keel, Williamson, & Crosby, 2007). Moreover, clinical presentations of disordered eating outside the defined categories of AN and BN comprise the greatest percentages of treatment seekers and have been repeatedly found to experience levels of detriment similar to diagnosable eating disorders (e.g., Andersen, Bowers, & Watson, 2001; Crow, Agras, Halmi, Mitchell, & Kraemer, 2002; Jorgensen, 1992; Le Grange et al., 2006; Martin, Williamson, & Thaw, 2000; Ricca et al., 2001; Striegel-Moore et al., 2000; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011; Turner & Bryant-Waugh, 2004). This has driven an even greater movement towards conceptualizing disordered eating on a continuum, with many researchers and clinicians now adopting a transdiagnostic approach (Fairburn, Cooper, & Shafran, 2003).

All this having been said, somewhere between unrestrained eating and disordered eating is restrained eating. Restrained eating can be defined as purposely restricting food intake, typically due to weight or shape preoccupation. Restrained eating classically involves dividing food into the dichotomy of forbidden or unforbidden based on the perceived nutritional properties of the food, such as fat, sugar, and calories. For example, a candy bar, which is high in fat, sugar, and calories, may be judged to be forbidden, while lettuce, which is low in fat, sugar, and calories, may be judged to be unforbidden. From the continuum perspective, restrained eating can thus stand alone, while it can also be a symptom of greater pathology when crossing over into diagnosable eating disorders (combined with other symptoms to form a clinical constellation).

Binge eating is another pattern of eating that can stand alone as problematic or occur within diagnosable disorders, including AN, BN, and binge eating disorder (BED), officially included in the diagnostic nomenclature of the APA as of 2013. Binge eating can be either objective or subjective.

Objective binge eating can be defined as the consumption, in a limited period of time, such as two hours, of an amount of food that would be considered unusually large compared to what most individuals would consume in similar circumstances, along with at least several of the following characteristics: (a) eating much more rapidly than usual; (b) eating until feeling uncomfortably full; (c) eating large amounts of food when not physically hungry; (d) eating alone because of being embarrassed by what or how much one is eating; (e) feeling disgusted with oneself, depressed, or very guilty after overeating (Spitzer et al., 1993).

Given that the consumption of large amounts of food is so often a common thread woven into the modern social fabric, context is really critical for this definition. For example, according to this definition, it is possible to plow through multiple plates of food at the buffet and enjoy the bounty at holiday meals without the eating being a binge because in these situations, most or at least many people would consume a similar amount of food. Indeed, an all-you-can-eat buffet invites you to literally eat all you can, and when it comes to holidays, the centerpiece of celebrations is often the menu, from the parade of food at Thanksgiving, the turkey heralding the way like the opening of the Macy’s Thanksgiving Day Parade, to the barbeques that are now seemingly synonymous with summer holidays, from Memorial Day to the Fourth of July to Labor Day, and the plethora of religious holidays, with their traditions of cherished dishes and desserts. It is still possible to binge eat in such circumstances, but for objective binge eating this would require clearly exceeding cultural norms, along with the requisite additional characteristics outlined above.

Likewise, when large servings are presented or packaged in a manner that suggests individual consumption, such as an a la carte menu item at a restaurant or a container of ice cream that fits into your hand so easily, it is arguably within reason to enjoy the portion presented, even if it would be otherwise categorized as multiple servings by caloric or nutritional yardsticks. This means that it is possible to eat a pint of Ben and Jerry’s or consume a massive entrée platter or serving bowl filled with a box of pasta when eating out and not be objectively binge eating.

In contrast, eating plate after plate of food at home on a regular weekday or more than a pint of ice cream would fall outside the definition of normative consumption in similar circumstances, meeting the criterion for an unusually large amount of food. At the same time, to be defined as binge eating, such behavior would still need to be accompanied by a sense of loss of control and several of the additional qualitative characteristics outlined above. Otherwise, the behavior may more accurately be termed overeating.

Subjective binge eating can be defined as eating an amount of food that would not be considered objectively large compared to what most individuals would consume in similar circumstances, but feeling out of control and experiencing several of the additional qualitative characteristics outlined above. In this case, cognitions—and, more specifically, judgments, are key. With subjective binge eating, someone can claim that they are binge eating when they are eating anything that is not within their definition of approval. For example, if sugar is considered forbidden, a binge could consist of one cookie or even a bite of a cookie; if only non-fat dressing is considered acceptable, eating a salad with a teaspoon of regular dressing could be a binge.

Grazing is another variant of overeating. Grazing refers to repetitive eating of unplanned, small amounts of food over a more extended period of time than a binge (for example, over the course of a day), accumulating to an objectively large amount of food, with a sense of loss of control (Carter & Jansen, 2012; Lane & Szabo, 2013; Saunders, 1999; 2004). For example, this could include a sense or pattern of eating more or less continuously throughout the day or during extended parts of the day (e.g., all afternoon; Lane & Szabo, 2013). While eating smaller portions throughout the day may be touted as a balanced form of eating to replace a more traditional pattern of three larger meals, grazing in this way, again, is accompanied by a sense of loss of control that distinguishes it as a more problematic pattern.

Theories of Restriction and Binge Eating

Several theories have been posited regarding the role of judgment in perpetuating restrained and disordered eating, including the Boundary Model of Compensation (Polivy, Herman, Olmsted, & Jazwinski, 1984), Restraint theory (Harnden, McNally, & Jimerson, 1997), the Spiral Model (Heatherton & Polivy, 1992), and Vitousek and Hollon’s (1990) Weight-Related Self-Schemata Model.

The Boundary Model of Compensation

The Boundary Model of Compensation suggests that restrained eaters regulate food consumption according to cognitive parameters, while unrestrained eaters predominantly use internal cues (Polivy et al., 1984). According to this model, unrestrained eaters essentially consume food when hungry and stop when sated. However, restrained eaters restrict their intake according to dietary rules, such as caloric limits. The maximum amount of food allowed determines the upper boundary of acceptable dietary consumption.

For restrained eaters, dietary disruptions then trigger eating more. This can be referred to as capitulating, which, defined colloquially, is the “screw it” factor or, more severely, the “fuck it” factor—basically thinking, “Well, I’ve already blown it, screw it, I might as well really go for it!” This is a form of imbalanced, all-or-nothing thinking.

Disruption can occur from consumption of a quantity of food perceived to be unacceptable; consumption of a forbidden food; stress; alcohol or other substance; or some other mechanism that overcomes cognitive inhibitions. The upper boundary of consumption for restrained eaters is then satiety. The upper boundary of consumption for individuals with eating disorders is nausea, physical inability to eat any more, or the termination of food availability (i.e., all the food is gone).

Restraint theory

Restraint theory emphasizes the role of cognition in eating as well (Harnden et al., 1997). According to Wegner, Schneider, Carter, & White (1987), suppression of a thought activates two opposing processes—Intentional Operating Process and Ironic Operating Process. Intentional Operating Process consciously searches for cognitive material unrelated to the suppressed thought, while Ironic Operating Process is consistently vigilant for the unwanted thought and ready to alert the individual if the thought occurs. As a result of the two processes contradicting each other, Intentional Operating Process falters, and, as a rebound effect, the individual experiences the thought even more frequently. According to this theory, suppressing thoughts about weight, food, and body shape actually increases such thoughts, leading to a preoccupation with weight, food, and body shape (Harnden et al., 1997). Furthermore, if an individual suppresses thoughts about their own weight and body shape, such thoughts will actually increase, leading to a preoccupation with his or her own weight and body shape. This preoccupation may motivate and sustain restrained eating. However, the continual bombardment of weight-, food-, and body-shape-related thoughts may cause breaks in willpower and thus lead to disinhibited eating.

The Spiral Model

Heatherton & Polivy’s (1992) Spiral Model describes a spiral of increasingly damaged self-esteem with chronic dieting that can cascade into the development of eating disorders. This spiral is fueled by judgment, often starting when individuals compare their weight or shape to their perceived ideals, prompting restricted eating if there is a perceived deviation judged to be in need of change. In contrast, such comparison is less likely to trigger restricted eating if individuals perceive no deviance from their ideals, or if they determine any perceived deviation as not cause for change. According to the theory and supporting research, low self-esteem further heightens vulnerability to restricted eating.

Then, because dieting seldom results in significant or lasting weight loss, most individuals who begin dieting will experience dietary failure. If individuals attribute failure to internal deficits, such as lack of willpower or effort, they may continue to diet, increasing their efforts to succeed. Unfortunately, increased efficiency in metabolic response increases the difficulty in achieving and sustaining weight loss. Thus, successive attempts at dieting often lead to successive failures. These failures can then diminish self-esteem and increase negative affect.

Furthermore, through this process individuals can become increasingly reliant on cognitive guidelines and rules for eating rather than internal cues, such as hunger. This increases their vulnerability to external eating cues and may lead to overeating in response to such cues. Overeating then prompts more dieting.

Clearly this is a vicious hamster wheel that leads to nowhere productive. Moreover, this spiral can, at its most extreme, promote increasingly pathological behavior, including more extreme restriction, fasting, excessive exercising, and even purging—patterns that can ultimately develop into diagnosable eating disorders.

Weight-Related Self-Schemata Model

Vitousek and Hollon (1990) suggest that individuals with eating disorders have weight-related self-schemata. These schemata combine views of the self with information about weight. Weight and body shape serve as the predominant determinants of personal value. Dissatisfaction with the self is deflected onto the body. Cognitive representations take the form of rules that follow the format of “If I am fat (or thin), I am … , I cannot (can) …, and I will be revealed as …” (p. 197). Fatness is associated with personal faults and flaws, and thinness is associated with self-control, virtue, beauty, and intelligence. According to this theory, in comparison with individuals who do not have eating disorders, individuals with eating disorders attach richer connotations to fatness, thinness, weight gain, and weight loss; construe themselves and others in more extreme terms; possess more detailed information about certain aspects of food and weight; possess more confidence about the correctness of their convictions about weight; view their beliefs about weight as particularly pertinent to the self; and assign a greater importance to weight-related domains and thus are more pleased by successes and distressed by failures related to these domains.

Psychological Consequences of Restriction: Research Findings

The White Bear effect

In a seminal study on thought suppression now known as the White Bear Experiment, Wegner and colleagues (1987) introduced a framework for understanding the impact of cognitive avoidance related to Intentional Operating Process and Ironic Operating Process. In this paradigm, participants in the experimental group were instructed to think about anything at all except a white bear and to indicate if they did think about a white bear by ringing a bell. They were also asked to share their thoughts aloud at the same time. What happened then was a fair amount of bell ringing and white bears showing up in the streams of verbalized thoughts (more than once per minute over the course of the five minutes of the task).

Participants were then told that they could think about anything at all and again, to verbalize their thoughts and indicate if they thought of a white bear by ringing a bell. Participants then verbalized more white bears and rang the bell more than participants who were not first instructed to not think about a white bear (the comparison group). In other words, there was a rebound effect from attempting to suppress the thoughts, such that the thoughts increased, compared to conditions without attempted suppression.

Subsequent studies suggest that the White Bear effect worsens with distraction (e.g., Arndt, Greenberg, Solomon, Pyszczynski, & Simon, 1997; Newman, Duff, & Baumeister, 1997; Page, Locke, & Trio, 2005, Wegner & Erber, 1992). For example, Wegner and Erber (1992) assigned participants to either suppress or focus on a particular target word; under each condition participants then engaged in a color-naming task (Stroop, 1935) while instructed to repeat either a nine-digit number (high cognitive load) or a one-digit number (low cognitive load). Stroop performance was worse, with more reporting of the target word, in the suppression condition with high cognitive load.

Relatedly, even earlier research similarly found that participants continued to report color associations when instructed to avoid making these associations. This suggested that they failed to cognitively block the associations, and the threat of being shocked for making the associations did not prevent this (McGranahan, 1940; Sears & Virshup, cited in Sears, 1943). Of course, paradoxically, perhaps the threat of shock made attempts at blocking even more difficult because then the cost of making the mistake was higher and so emotion was running higher, likely impairing efficiency.

Najmi and Wegner (2008) further demonstrated the White Bear effect in a cognitive accessibility paradigm. These researchers instructed participants to either suppress a thought or focus on it; under either condition participants then completed a task measuring reaction time influenc...