Dialectical Behavior Therapy for Binge Eating and Bulimia (14 page)

“The prompting event does not have to be a major event—it is just an event,
such as being alone in the house, that sets off an emotion that makes you
uncomfortable. And according to our model, this uncomfortable emotion is
something you want to go away or at least lessen in either duration or inten—
sity or both. Even positive emotions like joy can feel uncomfortable if you don’t
know how to manage them. And our assumption is that people with binge

The Pretreatment Stage

eating [and purging] problems have an underdeveloped, inadequate emotion
regulation system. This includes defcits in monitoring, evaluating, modify—
ing, and accepting emotional experiencing. You haven’t acquired the skills to
regulate your emotions.

“Food ‘solves’ this problem, so to speak. Temporarily it provides a way of
lessening your emotional experience by soothing you, helping you numb out,
taking your attention, and so forth. But the relief gained, as you know, is only
temporary. Using food doesn’t teach you effective ways of coping with your
emotional distress and therefore doesn’t solve the underlying defcit. The next
time an uncomfortable feeling comes up, the link you’ve made between emotional upset and eating is that much stronger.

“We think the problem is not
the emotion you experience, the emotion that
was triggered. In our view, the problem is the behavior you’ve learned to use
to cope with your emotions. In the long run, this behavior seriously lowers the
quality of your life, leading to more distress. It does not work to achieve the
desired effect of helping you feel better. It may provide a temporary distraction,
but eventually it causes more misery. It also may inhibit more adaptive emotional behaviors, such as asking for help. Numbing emotions with food leads
to a reduced chance of receiving validation, help, support, and the possibility
of change. It interferes with behaviors that may lead to true improvements in
your life.

“We want to help you break the link between having uncomfortable emotions and turning to food to cope. We will teach you more skillful ways of regulating your emotions so you can stop binge eating [and purging] and replace
the dysfunctional behaviors. These skills for gaining emotional control may
reduce emotional experiencing before the emotion starts in the frst place, or
they may modify the behavioral expression of an emotion that has already
been experienced. At this point, we’re not sure whether you just don’t have the
skills in your repertoire to act differently or whether the maladaptive eating
is so overlearned that it crowds out skilled behaviors that you do have. We are
assuming that even if you have some of these skills, you can still beneft from a
refresher to strengthen their use; you can also acquire new skills and practice
the skillful behaviors.”

TROUBLESHOOTING
D
IFFICULTIES

IN
O
RIENTING
TO
THE
E
MOTION
M
ODEL
OF
B
INGE
E
ATING

••
Example: “I don’t think I have any emotions before I binge. I don’t notice
any—just the urge to binge.”

••
Potential therapist reply
: “We believe that people are always experiencing
emotions. But because you have learned to turn to food so quickly to deal with emotions, you may not even be aware of them. Perhaps you have a glimmer of discomfort but all you’re aware of is ‘That dessert looks awfully good.’ We will help you in
this program get more skillful at observing and describing your emotions.”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
The Biosocial Model

This section involves giving clients background into the development of what this
model assumes is the primary and central problem in clients with disordered eating—an underdeveloped, inadequate emotion regulation system with defcits in
monitoring, evaluating, modifying, and accepting their emotional experiencing
(see also related material in Chapter 2). In other words, clients with binge eating (and purging) diffculties often feel depressed, angry, anxious, and out of control of their emotions. The inability to regulate emotion interferes with achieving
and maintaining a positive self-view and leads to low self-esteem. This, in turn,
may make them more emotionally vulnerable. Defcits in emotion regulation are
believed to stem from a variety of factors.

One assumption that makes it harder for clients with binge eating (and purging) problems to cope with their emotions is that they have a biologically based
increased emotional sensitivity compared with other individuals. It may not hold
true for all clients, yet, in our experience, individuals with BED and BN often
agree with this information and describe having been told throughout their lives
that they are “too sensitive.”

DISCUSSION
P
OINT:

“Have you been told that you’re too
sensitive, too ‘thin skinned’?”

A second assumption is that when clients with eating disorders do react, they
tend to have very strong impulses to act on their emotions and strong reactions to
their emotional experience, such as a sense that their hearts are pounding harder
and so forth. This emotional sensitivity, combined with a defcit in the ability to
adaptively regulate emotions, creates a very diffcult situation. Bingeing and purging are mood-dependent behaviors, and when feelings and urges to act on those
emotions arise, it is very hard to refrain from engaging in that behavior. This
treatment teaches skills to help clients gain control of emotions and behaviors so
that the two are not so tightly linked. It helps clients learn to tolerate strong feelings without having to do
something to stop them.

The Invalidating Environment
Another assumption of this model is that disordered eating behaviors develop
through an interaction between the client’s biologically based emotional sensitivity and a certain set of conditions, called the invalidating environment. In the
invalidating environment, emotions were not given time to be noticed or talked
about. On those occasions when they were noticed, they were not labeled accu—
rately or taken to be important. This set of circumstances would naturally cause
individuals to have diffculty in knowing and being able to label their feelings, in
trusting their own emotions as valid interpretations of what is taking place, and
in adaptively regulating their emotional arousal and reactions. It would be hard
to tolerate distress. And, indeed, if individuals were punished for expressing their
emotions, over time they would have learned to control and dampen down their

The Pretreatment Stage

emotions—eventually deciding not to show them or feel them. Instead, they would
learn to push away their emotional experiences, thereby self-invalidating their
feelings. Over time, they may have learned that food helps them to do this quite
well.

We have found the following teaching illustration helpful for demonstrating to
clients what we mean by the invalidating environment.

Illustrating the Invalidating Environment

Suggest that clients imagine a situation in which a small child goes to a carnival
and wins a goldfsh. Furthermore, they should picture a child who is emotionally
sensitive in the ways that were just described. Compared with other children, this
child has more powerful emotional reactions. When the child wins the goldfsh, for
example, he or she is absolutely overcome with joy—bouncing the bag up and down,
looking at the fsh repeatedly, poking at it through the bag, and so forth. The child
is clearly terrifcally excited and caught up in that excitement. Clients are then
asked to imagine that the following day the goldfsh dies. The child is devastated
and cries and cries—unable to stop sobbing about his or her disappointment and
desire for the goldfsh to come back. Therapists explain that in the invalidating
environment, the caregivers—for whatever reason—cannot tolerate their child’s
intense experience and expression of emotion. Perhaps the caregivers had grown
up in invalidating environments themselves or are depressed. In any case, the
caregivers feel the need to try to shut down the child’s emotions. In this scenario,
the caregivers unceremoniously fush the fsh down the toilet, saying: “Shut up!
Why are you crying? You only had that goldfsh for a day! If you don’t stop crying,
I’ll give you something to cry about!” Therapists highlight how the child’s inner
experience is not validated in this environment. With repeated episodes such as
this (not just a few), the child would learn not to trust his or her emotions. The
child would likely believe that something is wrong with him or her for feeling as
he or she does.

Therapists might also fnd it useful to offer another example, saying something such as:

“Thirst is an inner experience most people have no diffculty recognizing. But
imagine that you were raised in a household where that experience was invalidated because for some reason it was diffcult for your caregivers to respond
to. After years of being told, ‘You’re not thirsty, you just had a drink of water,’
how do you feel you would react? Most likely, you would have diffculty know—
ing your internal experience of thirst or how to handle it. That is what we’re
saying it is like when your emotions are invalidated.”

According to the model, another characteristic of the invalidating environment is that every once in a while the child’s extreme emotional display may be
reinforced. For example, the caregiver might react with sympathy when the child
seems especially overcome with emotion. This teaches the child to escalate the
emotional expression the next time, such as a child who is reinforced with candy

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

when his or her cries and tears become exceptionally strong. Therapists explain
that when rewards are given on an intermittent basis (e.g., intermittent reinforce—
ment), those related behaviors are particularly diffcult to change. In such pun—
ishing and intermittently reinforcing environments, the child would not learn to
communicate his or her emotional pain or distress effectively.

Another characteristic of the invalidating environment is that the child is told
overly simplistic methods for problem solving and regulating emotions, such as
“Just smile and the world will smile with you,” “Just decide not to feel that way,”
or “Pull yourself up by your own bootstraps!” Because of oversimplifying, the child
is not taught to tolerate distress or to solve the diffcult and complex problems of
living. Instead, he or she is likely to form unrealistic goals and to become highly
distressed by failure.

Illustrating Validating Environments

Revisit the imaginary scenario with the child who wins the goldfsh. Ask clients to
picture the same highly emotionally sensitive child, now devastated by the death
of the goldfsh. Yet in this scenario the caregivers, for whatever reason, have more
emotional resources. “Imagine the effect if the caregivers respond by saying, ‘Oh,
you’re sad. It hurts to have something you love die when you didn’t want it to. I can
see how much you wish things were different. How about writing a poem about it?
We’ll have a funeral ceremony and you can read it.’” The child in this environment
learns, with repeated episodes such as this, to trust his or her emotions as valid.
The therapists explain that although the child would always be emotionally sensitive, he or she would be more likely to learn ways to adaptively regulate his or her
emotional arousal.

DISCUSSION
P
OINT: “The consequences of having an invalidating environment may
include not being able to label your feelings, not trusting your emotions as valid, not
being able to regulate your emotions, and having a low tolerance for distress. Basically this
means not trusting your emotions about what is going on around you and judging yourself as
wrong for feeling as you do. Does that seem to ft for any of you?”