ACADEMIA Letters

A pilot intervention with mindfulness for inpatients with

Eating Disorders
Katya Sibele Stübing, Eating Disorders Division, Department and Institute of
Psychiatry, University of São Paulo (São Paulo, Brazil)
Tamara Anne Russell, Neuroimaging Department Institute of Psychiatry,
Psychology and Neuroscience, King’s College London (London, UK)
Taki Athanassios Cordás, Coordinator of the Eating Disorders Program AMBILUM,
Institute of Psychiatry, University of São Paulo (São Paulo, Brazil)
Francisco Lotufo Neto, Associate Professor, Department and Institute of Psychiatry,
University of São Paulo (São Paulo, Brazil)

Introduction
Eating Disorders (ED) are severe and complex psychiatric diseases leading to a range of patho-
logical behaviors. Authors in the field of ED have called for more research to develop new
psychological interventions that may help these clients, particularly the more severe ones (1,2).
Individuals typically diagnosed with Anorexia Nervosa (AN), Bulimia Nervosa (BN), or sub-
types are frequently engaged with mental health services yet evidence-based treatments are
scarce and show beneficial effects from none to moderate (1). These individuals present par-
ticular challenges due to the chronic nature of their illness, with recurrent treatments and
admissions, and high levels of co-morbidities (2).
Mindfulness training in adaptive forms has been investigated as a possible treatment in
ED (3). Although results from this burgeoning field are promising, the findings tend to mirror
what has been found in more established treatments such as cognitive behavior therapy (1,4)
(CBT). Both in the mindfulness and CBT literature, these approaches seem most efficacious

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Katya Sibele Stübing, [email protected]

Citation: Stübing, K.S., Russell, T.A., Cordás, T.A., Neto, F.L. (2021). A pilot intervention with mindfulness
for inpatients with Eating Disorders. Academia Letters, Article 4247. https://doi.org/10.20935/AL4247.

1
for those with Binge Eating Disorder (BED), and mild to moderate BN. For those with AN,
CBT has a weak evidence base, efficacy is limited (1,2) and this group is under-researched
in the mindfulness field. There are anecdotal reports that applying standardized mindfulness
protocols – such as Mindfulness-Based Cognitive Therapy (MBCT) or Mindfulness-Based
Stress Reduction (MBSR) – to these more severe in-patients may be contraindicated.
The T8SM-Crisis intervention1 drew on the over 30 years of meditation experience of the
lead author (KS) and the principles of the Body in Mind Training protocol (designed for use in
the in-patient setting for those with psychosis (10)). T8SM-Crisis works by training the basics
of mindfulness and compassion practices and psychoeducation, teaching how to apply them
to what is happening at the moment. It flexibly utilizes a semi-structured protocol as a method
of working informed by the psychopathology, but not directly targeting eating behavior. The
intention is to develop mindfulness in relation to current, meaningful scenarios, which can
be generalized to other situations (including more emotion-laden thoughts about food, body
weight, and shape).
In summary, this emerging field indicates that mindfulness may be helpful for ED but
there is a gap in knowledge about what works best for the more severe clients. The aim of this
pilot study was to investigate whether the T8SM-Crisis protocol is feasible, acceptable, and
efficacious in relation to general and specific psychopathology in these clients.

Methods
Design and procedures
Over four months in 2012, the T8SM-Crisis protocol was offered as an open rolling group
conducted by the lead author (KS) in the Eating Behaviors Ward, Institute of Psychiatry,
University of São Paulo (USP). This 8-bed unit offers a multi-disciplinary treatment to life-
threatening cases of ED who stay on average two months at the hospital with discharge to
outpatient care. All inpatients admitted were invited. Weekly sessions of roughly one-hour
duration were conducted after lunch. Each patient was evaluated individually, according to
admission and the number of sessions they attended. The ethics committee from the USP
Medicine School has approved the research. All participants provided written informed con-
sent. For more information about the program please contact the corresponding author.
1
The specifics of the intervention and details about its theoretical underpinnings are beyond the scope of this
article and are presented in a separate forthcoming paper.

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Katya Sibele Stübing, [email protected]

Citation: Stübing, K.S., Russell, T.A., Cordás, T.A., Neto, F.L. (2021). A pilot intervention with mindfulness
for inpatients with Eating Disorders. Academia Letters, Article 4247. https://doi.org/10.20935/AL4247.

2
Participants
Seventeen female inpatients diagnosed with AN (n=12), BN (n=3), or Eating Disorder Not
Otherwise Specified (EDNOS; n=2) participated in the training as an adjunct to usual treat-
ment. Data is reported on ten individuals who completed self-report measures. As expected
with this sample, there was a high rate of comorbidity with anxiety, depression, substance
misuse, and personality disorder. Mean age was 28.4 (18 to 46 years old). Mean age on ED
onset was 15.5 (range: 14 to 18 years old). Mean duration of ED was 12.9 (range 4 to 28
years of ED). Mean BMI on admission was 17.7 (range: 10.5 to 30) For n= 10, seven were
unemployed, one was student and two were employed. Nine were single and one was married.
Seven were Caucasian, two Afro-Brazilian, and one Asian.

Measures
Standardized self-report measures assessed general psychopathology (Beck Anxiety Inven-
tory – BAI (11); Beck Depression Inventory – BDI (12)), ED specific attitudes (Eating Atti-
tudes Test – EAT-26 (13)); mindfulness (Five Facets of Mindfulness Questionnaire – FFMQ
(14)), and body mass index (BMI).2

Data analysis
A non-parametric repeated measures ANOVA(15) was used to determine change over time.

Results
Table 2 shows that there were significant reductions in BAI, BDI, EAT-26, and the FFMQ sub-
scales Describing and Non-Judging. After investigating dosage impact, a significant reduction
in BAI was found.

2
BMI was calculated as kg/m2

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Katya Sibele Stübing, [email protected]

Citation: Stübing, K.S., Russell, T.A., Cordás, T.A., Neto, F.L. (2021). A pilot intervention with mindfulness
for inpatients with Eating Disorders. Academia Letters, Article 4247. https://doi.org/10.20935/AL4247.

3
TABLE 2: Means and standard deviations for two assessment points, p-values, and d-values

1 One participant did not complete BAI. There was no other missing data.
Note. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; EAT-26
= Eating Attitudes Test; EAT-26 Factor I = dieting; EAT-26 Factor II = Bulimia
and food preoccupation; EAT-26 Factor III = Oral control; FFMQ = Five Facets
of Mindfulness.

Discussion
A novel mindfulness intervention, T8SM-Crisis, was shown to be feasible and acceptable to
inpatients with ED alongside their usual multidisciplinary treatment. The group was run after
lunch-time, a period of high anxiety on the ward. This provided an opportunity for the T8SM-
Crisis approach to train individuals to engage directly with their suffering at the moment and
to highlight mental processes and habits that perpetuate and exacerbate distress.
Although these results are preliminary and in a small sample, it was demonstrated that
this intervention was sufficient to statistically reduce anxiety and depression. For BDI, scores
indicative of moderate depression pre-training were reduced to mild. There were also changes

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Katya Sibele Stübing, [email protected]

Citation: Stübing, K.S., Russell, T.A., Cordás, T.A., Neto, F.L. (2021). A pilot intervention with mindfulness
for inpatients with Eating Disorders. Academia Letters, Article 4247. https://doi.org/10.20935/AL4247.

4
in eating attitudes and increases in facets of mindfulness. BMI increased over the course of
the intervention. Due to a lack of a control group, these findings cannot be solely attributed to
the mindfulness intervention. A controlled trial was formulated based on these findings and
will be reported in a future paper.
An increased ability to describe mental, physical, and emotional experiences (measured by
the FFMQ) may have provided a way to access and change the alexithymia seen in this group.
Using the exercises in the protocol, participants were encouraged and supported to directly
notice and name what was going on. This process allowed them to gain some distance from the
experience – referred to by Shapiro et al. as “re-perceiving” (16) – and reduce affective distress
(17). Changes in non-judging also corroborate the experience of the facilitator who modeled
a non-judgemental stance and repeatedly (and gently) named and pointed to the relentless
tendency of this group to judge their thoughts, feelings, and experiences. Participants reported
it was helpful to explore a different way to be kind toward themselves, and the opportunity to
learn it.
The first target of T8SM-Crisis is to train the mind to stay focused so as to not get lost
in thinking. This was done by focusing on tactile sensations of body parts neutral to this
population and applying this as a tool to use during other parts of the day when they met any
challenge. Secondly, helping them recognize when they are in these strong mental patterns that
feel overwhelming, teaching de-centering and the ability to choose to do something different
with these thoughts - without judging or getting lost in them.
This work provides the first evidence for the utility of specially designed mindfulness
training for those with more life-threatening ED. The study was run by a very experienced
facilitator whose own personal practice of mindfulness allowed skillful and compassionate “in
the moment” flexible responding to even very distressing experiences. This way of working
requires significant training and skill and this must be considered in any future endeavor to
widen access to mindfulness as a treatment for these more complex and severe population. As
such, it must be considered a specialist intervention and due care and consideration gave to the
training of staff who might deliver this in the future. Limitations of this pilot were addressed
and the protocol was then submitted to a more controlled trial, that will be published in the
near future.

Disclosure
Statistical analysis was conducted by Bernardo dos Santos, a statistician from the Department
and Institute of Psychiatry, USP. The authors have no competing interests.

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Katya Sibele Stübing, [email protected]

Citation: Stübing, K.S., Russell, T.A., Cordás, T.A., Neto, F.L. (2021). A pilot intervention with mindfulness
for inpatients with Eating Disorders. Academia Letters, Article 4247. https://doi.org/10.20935/AL4247.

5
References
1. Treasure J, Claudino, AM & Zucker, N. Seminar: Eating Disorders. Lancet 2010; 375:583-
593.

2. Hay PJ, Touyz S, Sud R. Treatment for severe and enduring anorexia nervosa: a review.
Australian & New Zealand Journal of Psychiatry 2012; 46(12):1136-114.

3. Wanden-Berghe RG, Valero JS, Wanden-Berghe C. The application of mindfulness to

eating disorders treatment: A systematic review. Eating Disorders 2011;19:34-48.

4. Fairburn CG, Straebler SB, Basden S, Doll HA, Jones R, Murphy R, O’Connor ME,
Cooper Z. A transdiagnostic comparison of enhanced cognitive behavior therapy (CBT-E)
and interpersonal psychotherapy in the treatment of eating disorders. Behavior Research
and Therapy 2015;70:64-71.

5. Velden AMVD, Kuyken W, Wattar U, Crane C, Pallesen KJ, Dahlgaard J, Fjorback LO, Piet
J. A systematic review of mechanisms of change in mindfulness-based cognitive therapy
in the treatment of recurrent major depressive disorder. Clinical Psychological Review,
2015; 37:26-39.

6. Williams JMG, Crane C, Barnhofer T, Brennan K, Duggan DS, Fennell MJV, et al.
Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a ran-
domized dismantling trial. J Consult Clin Psychol 2014;82:275–86.

7. Kuyken W, Watkins E, Holden E, White K, Taylor RS, Byford S, Evans A, Radford S, Teas-
dale JD, Dalgleish T. How does mindfulness-based cognitive therapy work? Behavioral
Research and Therapy, 2010;48:1105-1112.

8. Teasdale, JD. Metacognition, Mindfulness and the Modification of mood disorders. Clin
Psychol and Psychother 1999;6:146-155.

9. Park RJ, Dunn BD, Barnard PJ. Schematic models and modes of mind in Anorexia Nervosa
I: A novel process account. International Journal of Cognitive Therapy, 2011;4(4):415-
437.

10. Russell TA, Tatton TR. Body in mind training: Mindful movement for the clinical setting.
Neuro-Disability and Psychotherapy 2014;1-2:108-136.

11. Beck AT, Epstein N, Brown G & Steer R. An Inventory for measuring clinical anxiety:
psychometric properties. Journal of Consulting and Clinical Psychology, 1988, Vol 56, N

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Katya Sibele Stübing, [email protected]

Citation: Stübing, K.S., Russell, T.A., Cordás, T.A., Neto, F.L. (2021). A pilot intervention with mindfulness
for inpatients with Eating Disorders. Academia Letters, Article 4247. https://doi.org/10.20935/AL4247.

6
 6: 893-897.

12. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh G. Inventory for measuring depres-
sion. Archives of General Psychiatry. 1961;4:53-63.

13. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes Test: psychometric
features and clinical correlates. Psychological Medicine, 1982;12:871-878.

14. Baer R, Smith GT, Lykins E, Button D, Krietemeyer J, Sauer S, et al. Construct validity
of the Five Facets Mindfulness Questionnaire in meditating and non-meditating samples.
Assessment 2008;Sep:15(3):329-42.

15. Akritas MG, Brunner E. Nonparametric models for ANOVA and ANCOVA: a review. In:
Akritas MG, Politis DN, editors. Recent Advances and Trends in Nonparametric Statistics.
Elsevier, 2003, p. 79-91.

16. Shapiro, S.; Carlson, L.E.; Astin, J.A. & Freedman, B. (2006). Mechanisms of mindful-
ness. Journal of Clinical Psychology, Volume 62(3): 373-386.

17. Lieberman MD, Inagaki TK, Tabibnia G, Crockett MJ. Subjective Responses to Emo-
tional Stimuli During Labeling, Reappraisal, and Distraction. Emotion (Washington, DC)
2011;11(3):468-480.

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Katya Sibele Stübing, [email protected]

Citation: Stübing, K.S., Russell, T.A., Cordás, T.A., Neto, F.L. (2021). A pilot intervention with mindfulness
for inpatients with Eating Disorders. Academia Letters, Article 4247. https://doi.org/10.20935/AL4247.