Dialectical Behavior Therapy for Binge Eating and Bulimia (30 page)

DISCUSSION
P
OINT:

“Any comments or reactions to these goals?”

MODEL FOR DESCRIBING EMOTIONS

An important frst step in learning to effectively regulate emotions is developing the
ability to identify and label all the various constituents of an emotional response.
Doing so breaks down the emotional response into a series of components, facilitat—
ing a person’s ability to understand what is happening and at which point he or
she might effectively intervene. The model for describing emotions (Appendix 5.2)
provides a schema for dissecting the various parts that make up the client’s emotional response so that she or he will be better able to understand, change, control,
modify, accept, or regulate her or his emotions.

Emotions are relatively short-lived phenomena. When an emotion lasts for a
longer time, it is called a mood. An emotional response may be sustained if it
becomes refred—for example, a client who is angry and ruminating may repeat
the same infammatory thoughts and images about the person with whom she or
he is infuriated. Emotion Regulation skills are intended to help clients learn how
to identify and interrupt unskillful sequences that contribute to unwanted emotion dysregulation.

Therapists use the model for describing emotions (Appendix 5.2) to highlight
the complexity of emotions, which involve the interaction of multiple systems. When
a client is anxious, for instance, the whole system is activated. The emotional experience includes changes in the brain, physical changes in the body, urges toward
action, and so forth. Underscore for clients that the good news with regard to such
a multifaceted system is that, by changing just one part of a response, clients can
change their emotional experience. Because it may be more diffcult to modify some
components as opposed to others, the key—after identifying all the parts of the
emotion—is to fgure out which would be the easiest to change. That said, empha—
size that this process is not effortless and requires perseverance and patience.

Therapists should reinforce the practice of Mindfulness skills in this context.
For example, the Observe and Describe skills are important for identifying the
trigger (prompting event) for an emotion. Emotions do not occur on their own;
something always triggers an emotion. Identifying what prompted an emotion can
be quite diffcult, yet doing so is a critical skill to develop. Mindfulness skills such
as Observe and Describe are key in this process.

Referring to the model, explain that prompting events may be internal triggers, including elements such as one’s thoughts, memories, or physical sensations.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

External events can also prompt an emotional response—for instance, if someone
yells at the client or someone close to him or her dies. Prompting events can occur
very rapidly and automatically, and therefore they can be challenging to detect.
Like an iceberg, the greatest portion lies under the water and is diffcult to see
from the surface. Similarly, underneath the emotion that is palpable and visible,
daily internal and external events that clients barely register may be those that
actually trigger many of the emotions that lead to the client’s binge eating (and
purging). Clients will beneft by practicing becoming more aware of their prompting events lying “under the water.”

Appendix 5.2 illustrates two ways in which prompting events may trigger emotions—directly or through an interpretation. Direct triggers, shown by the solid
lines, are ones that automatically stimulate the client’s entire emotion response
system without his or her having to think about it. An example would be the experience of fear on seeing a gun pointed at one’s face. Direct prompting events tend
to be rare.

More typically, the prompting event involves an interpretation that triggers a
client’s emotional experience (as shown by the dashed line from Prompting Event 1
to Interpretation of Event). Explain that how one interprets or understands events
will often depend on past learning and life experiences. For example, if you observed
your mother reacting with fear whenever a dog appeared, you might develop the
interpretation that dogs are always dangerous. Or, if you have experienced criti—
cism for voicing your opinion, then you might interpret situations in which others
ask for your opinion as highly risky and, therefore, feel anxious.

To further demonstrate the role of interpretations in emotional experiencing,
suggest that clients imagine the following scenario: “You have made an arrange—
ment to meet a friend. Upon seeing her, you notice she looks quite upset. Before
inquiring what is wrong, how might you interpret your friend’s apparent distress?”
After eliciting responses, invite clients to consider how the various interpretations
infuenced their emotional experiences. Therapists may suggest that, in their experience, clients with eating disorders have a tendency to avoid confict, but they
may not always be accurate about identifying the actual occurrence of confict.
For example, a client might interpret the absence of a smiling face on a friend or
spouse as an indication that the relationship is “in trouble,” leading the client to
feel depressed and/or anxious. Instead, the client’s friend or spouse may simply be
feeling cranky or annoyed for reasons having nothing to do with the client. The
important point being emphasized is that how a client interprets events greatly
infuences her or his emotional response.

Once the prompting event and the consequent interpretation have occurred,
a number of different reactions happen automatically and refexively as part of
the client’s ongoing emotional experience. For example, brain changes, such as
neurochemical signals, cause facial and body adjustments (e.g., alterations in body
temperature, heart rate, muscle contraction), and an action urge (e.g., to run, hide)
can be instantly triggered.

This discussion can help clients better understand the absurdity of instructing
themselves to “stop feeling” an emotion. When nervous about an upcoming inter—
view, for example, a client’s interpretation of the event as threatening will automatically lead to physiological responses, including a rapid heart rate, a fushed

Emotion Regulation Skills

feeling, and “gut clenching” nausea. Telling yourself not to experience these sensations would be like stepping into the rain without an umbrella and telling yourself
to stop feeling the wetness on your head.

There are means by which clients can shut off awareness of their emotions—
such as by using alcohol or food to produce sedative-like or activating effects. How—
ever, of course, the long-term cost of using these unskillful means is very high.
Attempting to control one’s emotional experience by binge eating to numb oneself
or to shut off awareness of bodily cues and signals may backfre and result in emotions building in intensity (e.g., Gross, 2006). It is diffcult to regulate emotions if
one is avoiding or purposefully overlooking emotional cues and signals. Therefore,
practice at registering bodily sensations of fatigue, anxiety, anger, and sadness
early on in the emotional sequence may make these emotions easier to identify,
understand, respond to, or manage.

DISCUSSION
P
OINT: “Are you aware of your body’s emotional signals or sensations?

Please describe. Is binge eating and/or purging one of the ways you typically attempt
to shut off awareness of your bodily cues? Which ones do you most typically attempt to ignore?
Do they tend to be emotion-related sensations (e.g., anger, sadness), or are they more apt to
be general body sensations, such as fatigue, hunger, or satiety?”

One of the most important functions of emotions is communication using both
nonverbal and verbal expressions. Individuals with eating disorders may likely
attempt to regulate their emotions through attempts to stop or alter these expressive pathways. For example, a client might try to hide or conceal her or his facial
expressions by smiling to cover or mask the fact that she or he is sad. Alternatively,
a client might try to conceal her or his emotion by exaggerating her or his facial
expressions. By taking on a somewhat theatrical or dramatic facial pattern, the
client can actually conceal what she or he is truly feeling.

DISCUSSION
P
OINT: “Is it diffcult for others to receive messages about what you are
feeling because you either restrict or exaggerate your emotional cues? Although there is
nothing intrinsically good or bad about how you express your emotions, you might fnd it helpful
to be aware of your tendencies so as to better consider the consequences.”

All the emotion components are included in the name given to the emotion (far
right of Appendix 5.2). These components include those not observable to others
that take place inside the client’s body, such as brain chemistry, sensations, and
urges, and those that are external and observable, such as body language, verbal
language, and actions.

Naming an emotion facilitates emotion regulation. Acknowledging what one is
experiencing is a frst step toward control. Accurately naming an emotion validates
one’s emotional experience rather than allowing others to determine what one is
experiencing or telling oneself what emotions “should” be present. This accurate
naming can have an extremely powerful effect. Often, clients with eating disorders
do not discriminate between their emotions. They tend to use automatic, global
descriptors such as “I feel stressed” or “I feel bad.” Therapists concede that taking

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

the time to observe and describe one’s emotions requires practice but that doing so
will enable clients to fgure out the precise feeling or feelings they are having, thus
aiding them in regulating those feelings.

Emotions can have powerful aftereffects on a client’s memory, thoughts, other
emotions, and ability to function (“Aftereffects” box in Appendix 5.2). It is natural
that an emotional response should not end with recognizing the emotion’s name but
instead stimulate additional thoughts, feelings, and reactions. The emotion’s aftereffects can prompt the refring of the same emotion or trigger a different emotional
experience (Prompting Event 2 in Appendix 5.2). For example, the aftereffects of
intense fear may temporarily paralyze a client’s ability to think and act; an aware—
ness of this immobility may trigger additional fear. Or the fear may prompt a different emotion, such as anger or shame. Therapists might say, “It is as if emotions
are in love with themselves, particularly when they have established strong asso—
ciations from past experiences.” Emotions will frequently recur, fring and refring,
until a component in the response system changes. Clients need to intervene in
only one aspect of the emotion response system in order to decrease, increase, or in
some way change an entire emotional response. The key is to intervene skillfully so
that the emotional response changes in the direction or manner one desires.

For individuals with eating disorders, a common aftereffect of an emotional
response is to label the emotion as “stupid,” instruct themselves to “snap out of
it,” or berate themselves by saying, “My feelings are wrong [or bad or shameful].”
These self-critical and invalidating responses become a prompting event (Prompting Event 2 in Appendix 5.2) for increasing emotional intensity and often trigger
a different emotion, such as shame, guilt, or depression. Research has found that
judging one’s emotions as invalid or wrong makes emotions even more intense
(e.g., Gross, 2006). Blocking an emotion increases physiological arousal, which
can lead to even greater urges to escape one’s emotion by turning to food. Thus,
although blocking or avoiding behaviors may distract one over the short run from
feeling certain emotions, the long-term consequences are often a buildup of emotions and the generation of other, secondary emotions. These can have devastat—
ing consequences over time on the health, self-esteem, and general well-being of
clients.