Introduction
Mindfulness-Based Eating Awareness Training (MB-EAT) (
Kristeller and Wolever, 2014;
Kristeller, 2016;
Kristeller and Wolever,
in press) integrates the science of meditation practice with the science of our relationship to eating, nutrition, food and body awareness, coupled with theories of self-regulation (
Carver and Scheier, 1998;
Shapiro and Schwartz, 2000). Clinical trials have shown significant improvement in eating regulation, both in those with and without binge eating disorder (BED), and improvement in depression (
Kristeller and Hallett, 1999;
Kristeller and Wolever, 2011;
Kristeller et al., 2013; Kristeller et al., in review). The core program has evolved over several decades, incorporating a wide range of mindfulness meditation practices, eating awareness practices, and guided practices linked to self-awareness and self-acceptance, and been adapted to a range of populations, including individuals with varying levels of obesity, with and without BED, and Type II diabetes (
Miller et al., 2012;
Daubenmier et al., 2016;
Mason et al., 2016).
Throughout the MB-EAT-based programs, regardless of variations, an integrative concept is the value of connecting to the ‘wise self’ in the service of self-regulation, as an alternative to drawing on externally imposed rules of dieting, food restriction, and socially imposed norms regarding body weight and appearance. What do we mean by the ‘wise self’ and how might this be connected to our ‘spiritual’ self? Although meditative and spiritual traditions are closely linked, this aspect of meditation-based practice, particularly within therapeutic contexts, has received relatively little systematic attention within contemporary research and theory. In some ways this is easily understood. Mindfulness practice is commonly – and usefully – framed as a cognitive process, in which attention is trained to rest gently on the breath or body experience, and then expanded further onto thoughts or particular emotional experiences, without being drawn into reactive or judgmental conditioned responses. The intent, drawn from traditional Buddhist theory, is to release the mind from highly conditioned reactivity or suffering, both in the moment and in more extended ways. Such effects have been clearly documented in areas of reduced stress reactivity, and improvement in behavioral and emotional self-regulation (
Wachholtz and Pargament, 2005). The contemporary concept of ‘wisdom’ is also usefully drawn upon; it will be argued that this term implies greater access to parts of the brain that can improve self-regulation and well-being when presented with complex choices, as is true in many aspects of daily life, but that wisdom does not necessarily entail spiritual engagement, as it extends into all areas of functioning (
Sternberg, 1990,
1998;
Schwartz and Sharpe, 2010).
A growing area of research over the last 20 years has demonstrated the importance of spiritual engagement, as a psychological construct distinct from religious involvement (
Hill et al., 2000;
Koenig L.B., 2015), in many different populations including emerging adults, individuals with chronic illnesses, psychiatric patients, and older adults (
Koenig H.G., 2015;
McCarthy et al., 2015;
Akin and Akin, 2017;
Da Silva and Pereira, 2017;
Chaar et al., 2018). The construct of spirituality has been examined in a multitude of ways including meaning in life (
Bloch et al., 2017), purpose, spiritual coping (
Charzyńska, 2015), compassion, and spiritual experiences (
Knabb and Vazquez, 2018). These studies reflect a growing accumulation of research that suggests spirituality is associated with improved mental health, quality of life, and adjustment.
While the expression of spiritual experiences may be varied, the capacity for spiritual engagement may be more easily measured by assessing the components of spirituality such as meaning, peace, an experienced connection with religious faith/beliefs, and connection with something sacred/universal. The authors of the present article believe that this capacity for spiritual engagement is virtually universally reflected in many peoples’ desire to “step back” from their strivings and efforts to experience a more content and spiritual life. While often overlapping with religious engagement, it is understood to refer to underlying psychological experience, not inherently linked into culturally specific (or personally significant) sets of beliefs (
Atchley, 2009).
Individual differences in spirituality are assessed through a variety of self-report measures, with one of the important distinctions among measures being the degree to which specific beliefs are still referred to, or incorporated into the measure (such as belief in God). One of the most prominent measures, the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being subscale (FACIT-Sp), assesses two factors, Meaning and Peace, and Faith (
Peterman et al., 2002). It was developed to be applicable across individuals from different faiths, including atheists, demonstrates good psychometric properties, and is frequently used in the health literature. Cross-sectional studies suggest that meaning, peace, and faith beliefs as measured by the FACIT-Sp are associated with quality of life in cancer patients as well as self-reported emotional equanimity, better cognitive functioning, and social support (
Kristeller et al., 2011;
Jordan et al., 2014;
Chaar et al., 2018). Interventional studies using a variety of mindfulness-based treatments have led to improvements in health-related quality of life (
Gross et al., 2017), reduced chronic pain-related stress (
Feuille and Pargament, 2015), and spirituality as assessed by the FACIT-Sp (
Fish et al., 2014). Use of it to measure spiritual well-being in the MBSR program demonstrated significant increases on both factors, correlated with increases on measures of mindfulness and improvement on other measures of well-being, including depression, anxiety and reported medical symptoms (
Carmody et al., 2008).
To the extent that mindfulness can lead to spiritual engagement (
Kristeller and Jordan, 2018), it is expected that health benefits likely accrue in part due to improved psycho-biological regulation (for review, see
Hulett and Armer, 2016). These improvements may also interact with improved behaviors that are associated with health. For example, prayerful states and meditation are associated with activation in the prefrontal cortex (
Newberg and d’Aquili, 2001;
Azari et al., 2005;
Seybold, 2007;
Goleman and Davidson, 2017), an area of the brain that plays a role in self-regulation. In much the same way as a muscle, “working out” one’s self-regulation muscle may provide it with greater strength and ability to apply it in other ways and settings (
Baumeister et al., 2006). Meditation training has been shown to improve self-regulatory processes and outcomes, lower cortisol responses, and increase secretory immunoglobulin A responses (
Tang et al., 2007).
Exploring these processes within the arena of eating behavior may seem like an unlikely context. After all, food choice is about survival, basic health, pleasure, neither over-eating nor under-eating, but not necessarily about engaging any level of higher meaning or experience. The ways that mindfulness helps focus awareness on eating experience, thoughts, emotions, body acceptance, and managing stress reactivity should well suffice for understanding the increasingly substantial evidence regarding the value of mindfulness-based eating programs (
Godfrey et al., 2015).
Eating-related practices are carefully informed by research on food intake regulation, such as heightening awareness of physiological vs. environmental or emotional ‘hunger’ triggers (
Polivy and Herman, 1999;
Wansink et al., 2005;
Crespi and Unkefer, 2014); the role of sensory-specific satiety (referred to in the program as taste satisfaction/‘taste-satiety’) in modulating food intake (
Guinard and Brun, 1998); awareness of stomach fullness to signal the end of a meal (
Geliebter and Hashim, 2001;
Herbert et al., 2013); and the natural variability and flexibility of eating patterns observed in ‘balanced’ eaters (
Kristeller and Rodin, 1989). The program emphasizes eating for ‘quality over quantity,’ or deriving enjoyment from the moment-to-moment experience of eating, rather than from the amount of food ingested, thereby shifting the reward value of food without removing it (
Stice et al., 2009).
Yet the broader intention for MB-EAT is helping individuals to let go of over-preoccupation with issues related to eating and weight, shifting their focus and energy back onto higher level concerns and values in their lives. The program draws on the perspective that all aspects of human functioning can be heightened through the use of mindfulness practice, and that these include spiritual capacity as part of cultivating wisdom (
Young-Eisendrath and Miller, 2000;
Kristeller, 2003;
Jeste et al., 2010). MB-EAT draws on the concept of ‘wisdom’ throughout the program. From the first session, the concept of wisdom is introduced to underscore the value of mindfulness practice to look inside oneself for how to make choices about what to eat, when to eat, how much to eat, rather than depending on the strict rules of the dieting mentality. The use of the term ‘wisdom’ seems to resonate strongly with program participants, as does the program’s emphasis on flexibility, letting go of self-judgment and searching in a flexible way to develop new patterns of eating and food choice. (
Kristeller, 2003,
2007).
We emphasize that ‘wiser’ alternatives may become apparent, even in the middle of eating, by gently bringing into one’s awareness new alternatives. As an example, a woman in our program confessed that she often ate donuts that had been brought into her office’s breakroom guiltily and compulsively. She came to Session 5, excitedly sharing that someone had brought in a box of donuts that week, and that she’d responded quite differently. She’d first checked that she was actually physically hungry, mindfully chose a donut that particularly appealed to her, and brought it back to her office to allow herself to fully attend to the experience. She noted that the first bite was exceptional (with no flavoring of guilt), the second bite was almost as good – but that the third bite was too sweet, too greasy, and the chocolate icing had lost its flavor. She paused, breathed – and threw out the rest of donut. She exclaimed to the group that she had never thrown out partially eaten food before in her life. This is an example of connecting with the ‘wiser’ self.
The MB-EAT program (
Kristeller and Hallett, 1999;
Kristeller and Wolever, 2011;
Kristeller, 2016;
Kristeller and Wolever,
in press) incorporates a wide range of mindfulness-based practice, including sitting meditation practice; ‘mini-meditations’ lasting from a few moments to a few minutes, to be used while eating and at other times; guided eating practices, beginning with four raisins, and then incorporating increasingly challenging foods and food situations; guided meditations; and substantial home practice and group discussion. Again, the term ‘wisdom’ is used in many of the guided meditations, culminating in a Wisdom Meditation in Session 10. It is not until this practice that the word ‘spirituality’ is explicitly mentioned, yet it is not uncommon that participants, most of whom identify as Christian, note that their meditation practice sometimes evokes the tone of prayer, and that they have had multiple spiritual experiences as part of their meditation experience.
This leads back to the original question. How might our concepts of ‘wisdom’ and ‘spirituality’ be understood, both experientially and within the neuro-science of functioning, as related to cultivating capacities linked to mindfulness practice? These terms are often linked in the literature on the value of religious and spiritual practices, with an appreciation that these traditions help individuals not only to experience their own spirituality more deeply, but also help them to engage wisdom and greater well-being for themselves and in their communities (
Young-Eisendrath and Miller, 2000;
Henry, 2013). Given these strong historical linkages, it may be that meditation practice, in loosening the domination of highly conditioned reactive patterns related to survival behaviors (such as eating), and emotional responses that may be largely seated in the lower brain regions, inherently opens up access to those parts of the mind involved in spiritual experience. And it then may be that these spiritual experiences engaged during meditative practice ‘feed back’ to modulate the power of these more primitive linkages by facilitating access to more complex choices, or ‘wisdom,’ heightening overall self-regulation (
Kristeller, 2007;
Sharp, 2011).
Therefore, the specific aims of this paper were to explore whether earlier results regarding the impact of the MBSR program on spiritual well-being (also measured by the FACIT-Sp) (
Carmody et al., 2008) would extend to a more focused mindfulness-based program, in regard to emotional and eating-related outcomes, and to explore the role of changes in mindfulness, as measured by the FFMQ, on such effects. Note: the primary results of the current randomized clinical trial are reported elsewhere (Kristeller et al., in review).
Discussion
The results found in this study for the effects of MB-EAT on spiritual well-being and their relationship to other variables are largely parallel to those found in previous research investigating the effects of MBSR on spiritual well-being (
Carmody et al., 2008). Although the increases in the MB-EAT program on the FACIT-Sp values from baseline to immediate post were somewhat smaller than for the MBSR program, as is understandable, given the more substantial focus on mindfulness practice
per se in the MBSR program, they were still meaningful in their relationship to other changes.
Also similar to the results found in the MBSR study are the clear relationships between increases in Meaning/Peace and Faith and decreases in depression anxiety, and program-targeted symptoms: health-related for the MBSR program and binge-eating symptoms for MB-EAT, with these relationships in both studies somewhat stronger for Meaning/Peace than for Faith. In the current study, this pattern was sustained and was even somewhat stronger at the 2-month followup, suggesting the effects of the treatment, particularly via increased Meaning and Peace, were still present past the conclusion of the weekly treatment phase, evidence that was not available for the MBSR study. Overall, the findings related to Meaning and Peace are quite consistent with recent research and writings emphasizing a meaning systems framework for conceptualizing the effects of religiousness and spirituality (
Paloutzian, 2017).
The change in the Faith factor was more consistently related to changes in the FFMQ at immediate post, correlating with four factors, whereas change in the Meaning and Peace factor was significantly related only to change on the Describe and Observe factors. This finding is somewhat perplexing because the item content of the Meaning and Peace factor (e.g., purpose, harmony) seems to correspond more fully with the practice of mindfulness. It is possible that the predominantly Christian population in the current study rendered the Faith factor more relevant, especially as it relates to the factors of the FFMQ. At the same time, our exploratory analyses suggest that the Meaning and Peace factor of the FACIT-Sp fully mediates the relationship between initial change (at immediate post) on the FFMQ Observe factor and its relationship with improvement in both uncontrolled/emotional eating and post-treatment depression. One reason the Observe factor may link with the Meaning/Peace factor is that all items loading on this factor are mostly positive in content, related to experiencing body/sensory feelings, such as “I pay attention to sensations, such as the wind in my hair or sun on my face.” The other FFMQ factors are either all or mostly reverse-scored, such that they indicate ‘mindlessness’ as worded, or for ‘Non-reactive,’ tap into NOT reacting to generally negative situations. Future research is needed to examine how engaging mindfulness and other meditation-based interventions relate to different aspects of spirituality.
It is worthwhile to consider further the evidence for the self-regulatory value of spiritual well-being on behavior, consistent with a linkage between spiritual/faith engagement and the concept of wisdom, over and above the positive emotional value of such spiritual experiences or possible effects on depression. Related to this, in our earlier research using MB-EAT with individuals with BED (
Kristeller et al., 2013), absolute improvement on the BES and depression was comparable between the two intervention groups. However, for the participants receiving the Psycho-Ed/CBT intervention, improvement in eating regulation was highly correlated to decreases in depression, but completely unrelated to change in depression for those in the MB-EAT condition. Improvement in spiritual well-being, which was not measured in that study, may have therefore been playing a similar important mediating role.
Improvement in compulsive and emotional overeating is largely a function of ongoing behavioral change, suggesting that individuals who experience heightened spiritual well-being, may also be more fully engaging what we refer to as ‘wisdom’ within the intervention, while letting go of the chronic struggles around food, their weight and their sense of self that they had previously experienced. To the degree that this pattern is consistent with mindfulness-based programs, encouraging more active engagement of the spiritual self might be integrated into such programs, consistent with guidelines for doing so (
Pargament and Faigin, 2012;
Plante, 2016). In addition, it would raise questions about policies that stipulate avoiding doing so as religiously biased or inappropriate. One woman, who entered the program with BED, shared her extended experience with MB-EAT in an informal followup interview several years after completing the program. She noted that she was no longer binging with any frequency, but while she was rarely practicing formal meditation, she frequently used mindfulness and breathe awareness. She also attributed much of her self-growth, not only in regard to eating but also in relation to other areas of her life, to the meditation training and practice, noting “it helps me hook into my inner wisdom. Meditation slows you down enough to be in touch with God … and God lives in all of us” (
Kristeller, 2007).
This study has several limitations. First, there was a relatively high drop-out rate, and the possibility of self-selection effects cannot be completely ruled out. However, our drop-out rate is similar to other studies (
Carlson et al., 2016). Second, we only used one measure of spirituality. There are other measures available including the Spiritual Transformation Scale (
Cole et al., 2008), the Sources of Spirituality Scale (
Davis et al., 2015), and the Spiritual Transcendence Scale (
Piedmont et al., 2008). Given the debate about the construct of spirituality, using multiple measures, with somewhat distinct conceptualizations of spirituality, may help future researchers to determine which aspects of spirituality are most sensitive to interventions involving mindfulness. Finally, although followup assessment in the current study continued out to 6 months post-intervention, these did not include the FACIT-Sp past 2 months, so that longer term assessment of spiritual engagement might have more fully illuminated the underlying processes. Another limitation is that no measures of wisdom were included; such measures are now under further development (
Jeste et al., 2010;
Noghabi and Nabizadeh, 2017).
The psychology of spirituality continues to move in exciting directions and the rich history of mindfulness and associated interventions will continue to cross paths with this field. This is a good thing. As a universal human capacity, understanding the psychology of spirituality needs to be engaged rather than ignored, neglected, or written off. In the quickened world we live in, slowing down the associated reactivity is difficult, but to the extent that mindfulness can do this, the human capacity of spirituality – which has served humanity for millennia – can continue to do so in the 21st century.
