Dialectical Behavior Therapy for Binge Eating and Bulimia (33 page)

DISCUSSION
P
OINT: “Take a moment to think about times when your emotions are
giving you information about a situation versus giving you information based on your
past learning experiences.”

Although there are helpful ways that emotions communicate to us, thera—
pists draw clients’ attention to additional examples of how overreliance on one’s

Emotion Regulation Skills

emotions can lead to diffculties. When a client uses her or his emotional reac—
tions to confrm
what she or he already believes to be true, it is diffcult for her or
him to appraise situations objectively. Examples include: “Because I feel worthless, then I must
actually be worthless”; “If I am furious with my boss, then he
must
be an insensitive tyrant”; or “If I feel angry with you, it proves you
must
be wrong.”

Understandably in such instances, as therapists explain, modifying one’s
intense negative emotions can feel especially invalidating. This presents a diffcult
situation for clients. The way out of the trap is for clients to validate their entitle—
ment to feel exactly as they do (e.g., legitimizing their “right” to feel angry) while
simultaneously accepting the facts or the reality of the situation (e.g., that aspects
of the other person’s argument may be accurate).

DISCUSSION
P
OINT: “Have there been times when you treated as facts the information
provided by your emotions? Would changing the negative emotions have felt
invalidating? Can you recognize any links to binge eating?”

Therapists may fnd it helpful to emphasize the following, particularly for clients having diffculty validating their emotions. Having emotions is part of what
it means to be a human being. As noted, one’s emotions are biologically hardwired
responses. At the most basic level, emotions must be acknowledged in the same
way one acknowledges sensations such as heat from the sun or moisture from the
rain. As brought up earlier, trying to ignore the existence of uncomfortable emotions would be like saying, “I don’t like the sensation of feeling wet, so I’m going
to pretend my hair isn’t soaked with water.” Unless one is willing to acknowledge
an emotion, he or she cannot decide what to do. Ignoring the fact that one’s head
is wet, for example, means that one cannot assess the situation objectively before
reacting (e.g., determining whether the water is due to a leaky roof or a fre sprin—
kler going off due to a fre).

Therapists underscore that the client’s wish
to rid her-or himself of discomfort is always valid. Wanting to bypass experiencing a distressing emotion and its
related urges through binge eating is an understandable desire. But now the client
has other options for comforting her-or himself that hold promise of being ulti—
mately more effective. Learning to think about the function of the emotion rather
than just trying to get rid of it or diminish awareness of it is an effective strategy
in itself.

JUSTIFIED VERSUS UNJUSTIFIED EMOTIONS

Therapists convey their belief in the usefulness of a concept that may be new to the
client—that of justifed versus unjustifed emotions. This concept does not invalidate the earlier discussion that all emotions are valid; but whether an emotion is
justifed
depends on whether it is warranted by the particulars of a situation. Therapists explain that, for example, feeling panic during a severe earthquake would
be considered a justifed emotion. It may not be effective
for a client, who may still

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
wish to regulate her or his experience of that emotion so as to be able to think and
act as clearly as possible, but the emotion itself
is justifed. On the other hand, feel—
ing that same amount of panic on entering an elevator is unjustifed
because the
actual likelihood of danger is very, very low. Again, this is not
the same as saying
the emotion is invalid or wrong. The emotion may be highly understandable, per—
haps being based on having once been trapped in an elevator. But it is considered
unjustifed based on its timing (i.e., if the current situation does not warrant it) or
on its intensity not being appropriate to the circumstances.

Therapists describe how the ability to distinguish between justifed and
unjustifed emotions can enable the client to step back from being caught up
in her or his emotions. Validating her or his emotion while simultaneously rec—
ognizing the effectiveness of regulating its intensity is a highly useful skill.
Therapists caution, however, that it is not useful for a client to become overly
caught up in distinguishing between justifed and unjustifed emotions, as there
can be instances in either case in which it makes sense for the client to try to
change his or her emotion. For example, rescue team members working during
the unstable conditions of an earthquake may feel fear, which is justifed given
the situation, yet may wish to reduce its intensity in order to more effectively
perform their jobs.

Binge Eating (and Purging) as an Emotional Expression
Therapists may wish to take this moment to step back and review with clients the
assumption, fundamental to this treatment approach, that a client’s binge eating and other problem eating behaviors are components of her or his emotional
response system. Specifcally, like the action of feeing when afraid, binge eating
can be understood as part of the “action component” of an emotional response. The
client’s binge eating (and purging) may serve many purposes, including communicating to others, infuencing others, and communicating to oneself—whether the
client intends these things or not. Because of the way binge eating functions for the
client, changing her or his behavior, despite her or his strong desire to do so, can
feel extremely challenging, and the client should not lose heart. Therapists explain
that binge eating (and purging) has been a “quick fx” or short-term means of regulating her or his emotions. But as the client is well aware, the effects of this type
of “fx” dissipate quickly. Practicing and applying the Emotion Regulation skills in
treatment requires more time, but therapists emphasize that its benefts may last,
without the many debilitating negative consequences of binge eating.

TROUBLESHOOTING
D
IFFICULTIES
IN
T
EACHING
THE
F
UNCTION
OF
E
MOTIONS

••
Example 1: “Why would I want to hold onto an emotion if it distorts my per—
spective?”

••
Potential therapist reply: “People often hold onto their emotions because they
are afraid that if they let them go, they won’t have had a right to feel the way that

Emotion Regulation Skills

they do; they will have been ‘wrong.’ Recognizing the function of one’s emotion can
be very helpful when you realize there are
reasons for the way you feel, whether or
not the reasons are apparent, and these reasons exist even when you decide it is in
your best interest to change how you feel. For example, imagine someone is criticiz—
ing you and you are angry. You don’t want to feel this level of fury, but you don’t
know how to let go of your anger without also losing your justifcation for having it.
The trick is to fnd a way to validate your emotions while maintaining perspective
regarding the reality of your situation. This involves learning to hold onto the dia—
lectic between many opposing truths that are simultaneously possible. For example,
it’s possible to believe you are right but not to hold onto your intense anger, just as
it’s possible to feel some anger while also acknowledging that potentially the other
person has a point. The goal of this treatment is to help you understand the function of emotions so that you don’t turn to binge eating as a way to ‘solve’ a confict
through numbing your feelings or by using a secondary emotion, such as becoming
angry or ashamed at yourself, to block your primary emotion.”

••
Example 2: “Are you saying that we should always reduce our intense emotions?”

••
Potential therapist reply: “We are only referring to situations in which it would
be effective to change or to reduce your emotion’s intensity rather than engaging in
binge eating and/or purging as a way of numbing. We aren’t suggesting you should
always want to reduce the intensity of your emotions.”

SUGGESTED
HOMEWORK
P
RACTICE

Encourage clients by reminding them that identifying the function of their emotions, as well as continuing to practice observing and describing these emotions,
can signifcantly help to reduce their binge eating (and purging) and other prob—
lematic eating-related behaviors.

1.
Therapists instruct clients to fll out an “emotion diary” to gain experience
in thinking about the function of emotions. Clients should list fve emotion entries
per week and, for each, identify one or more of the emotion’s functions. Clients may
choose the strongest emotion felt on a particular day or perhaps one experienced as
particularly troubling.

2.
Therapists instruct clients to complete the Observing and Describing Emotions Homework Sheet (Appendix 5.5) for at least three of the fve emotion diary
entries.

3.
Therapists ask clients to observe what happens after they attempt to identify the function of their distressing emotions. Communicating about the emotion
to oneself, for instance, sometimes helps to reduce its intensity. If the client does not
notice this effect, he or she might consider communicating the emotion to someone
else or allowing the function of the emotion to be expressed via a more effective
means than binge eating (and purging).

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
REDUCING VULNERABILITY TO EMOTION MIND

The rationale for teaching the skills in this section is that binge eating, purging,
and other problematic eating behaviors are more likely to be used when the client
is in Emotion Mind and her or his emotions are dysregulated. Hence, identifying
and changing factors that make a client more vulnerable to her or his Emotion
Mind is key.

Check with clients about patterns they may have noticed regarding their vulnerability to engage in binge eating. Typically, clients realize that during times
when they are tired, ill, and/or extremely hungry, they are more emotionally reactive and more likely to turn to food to soothe themselves. By targeting the specifc
behaviors that make them more vulnerable to Emotion Mind, clients can begin to
break the links between those behaviors and problematic eating.

Six guidelines for reducing emotional vulnerability are discussed in this section (and described in greater detail in Emotion Regulation Handout 6 in Linehan,
1993b, p. 154). While reviewing these guidelines, therapists help clients to identify
their emotional vulnerabilities, to observe and describe how these infuence their
emotional reactivity, and to increase their awareness of how these factors inten—
sify their problem eating behaviors. Suggested probes are offered here. Having
identifed the specifc areas of vulnerability, therapists encourage clients to think
through ways to address these vulnerability factors in the future.

Treating Physical Illness

“Do you notice patterns of turning to food when feeling physically unwell?” Many
clients with eating disorders have a tendency, as mentioned, to distract themselves
from awareness of their bodies. “Do you try to ignore your body’s messages when
feeling sick so as to be able to function the same as always?” Ask clients to think
through the costs of such behaviors. “Can you afford to keep paying this price?
Compared with treating physical illness directly, how does binge eating [and purging] affect your short-and long-term functioning? What behaviors need to change
in order to reduce this source of vulnerability?”