Dialectical Behavior Therapy for Binge Eating and Bulimia (31 page)

In order to be skillful in responding to one’s emotions, it is important to distin—
guish between one’s primary emotion (the original or frst emotion felt) and one’s
secondary emotion (the emotion felt as a consequence of one’s response to the primary emotion). Over 2,500 years ago, the Buddha recognized this phenomenon and
stated that humans tend to cause themselves unnecessary suffering by shooting
themselves with a second arrow. That is, the Buddha acknowledged that we cannot
avoid all pain in life (getting shot with the frst arrow) but that we can
make wise
choices and not cause ourselves additional pain by following the frst arrow with a
second! Unfortunately, all too often, individuals with eating disorders shoot that
second arrow by responding to their own pain in negative, critical, and unskillful
ways. Clients frequently fall into the trap of labeling their painful emotions rather
than their responses to the emotions, such as binge eating and other maladaptive
eating behaviors, as “the problem”. Though painful emotions are often distressing,
therapists point out that the problem is more correctly identifed as attempting to

Emotion Regulation Skills

block or numb the emotions. How one chooses to act or not act on his or her feelings
is critical. It is possible to respond to primary painful feelings with understanding,
interest, compassion, or myriad other skillful reactions that may lead to a decrease
in emotion intensity and an increased sense of mastery.

DISCUSSION
P
OINT: “Think of a time when you had a primary emotion and a secondary
emotion. Did your response to the primary emotion lead to feeling better ... or cause
more trouble and grief?”

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to use the Primary Emotions and Secondary Reactions
Homework Sheet (Appendix 5.3) to write about the experience of observing their
primary and secondary emotions.

In order for clients to regulate their emotions effectively rather than turning
to food, they must have a constructive relationship with their feelings. This will
likely be a new experience. As clients probably recognize, individuals with eating
disorders often use food to express their emotions. For example, they may express
irritation with family members by sitting in front of the television with a bag of
chips and a pint of ice cream and effectively walling themselves off.

Clients will also likely recognize that the type of relationship they have had
with their feelings has been destructive to them and to their relationships with
others. Therapists use this recognition to underscore the importance of practicing
the skills of observing and describing the components that make up clients’ emotional responses in order to help them build a more constructive relationship with
their emotions. A useful guide for practicing observing and describing emotions is
found in Linehan’s (1993b, pp. 139–152) emotion regulation handout 4 on “Ways to
Describe Emotions,” a brief synopsis of which is given in Appendix 5.4.

In summary, the ability to identify emotions and their components can enhance
the client’s ability to regulate them. This involves identifying the prompting event
for a client’s emotion, her or his interpretation of the prompting event, her associ—
ated physical and body changes, emotional expression, and the aftereffects of the
emotion. With increased awareness of these many components of her or his emotional response, the client has more opportunities to intervene and thus change her
or his emotional response. For example, if a client notices muscle tension as part
of her or his emotional response, she or he can stop and take a few deep breaths to
relax. Or if a client notices that her or his interpretation of a situation is infam—
ing her or his emotional experience, she or he can practice considering alternative
interpretations that would lessen the intensity of the emotion.

DISCUSSION
P
OINT: “Do you think that you use binge eating [and purging] as a way
to express certain emotions, such as frustration or irritation? And/or does your binge
eating serve to express certain action urges, such as the urge to rebel?”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to look over the Synopsis of Ways to Describe
Emotions (Appendix 5.4), explaining that its purpose is to help clients confused
about what they are feeling by giving examples of the components of universal
emotions. Clients might begin by looking at the various emotion words to fnd the
ones that best describe how they are feeling. They can then look over the prompting events to determine whether any apply and try to understand their relevance
by using the examples of interpretations that often accompany that emotion. In
this manner, clients may gain practice sorting through their emotional responses,
including bodily expression, action urges, and so forth.

2.
Therapists instruct clients to fll out the Observing and Describing Emotions Homework Sheet (Appendix 5.5, based on Linehan, 1993b, p. 162) about a
recent emotional experience. (An example of a completed homework sheet is pro—
vided in Figure 5.1.) After having done so, clients should try to identify points at
which they could have intervened to change their emotional experience. Therapists
might suggest that clients select other colors of pen to write down other possible
interpretations, other bodily experiences they might have had (e.g., relaxing the
shoulders instead of tensing them), and other things they might have said or done.
Clients should consider the emotions they might have experienced if, at the time,
some of these emotional components had been altered. Might it have lessened the
sense of intensity or urgency experienced or the untoward consequences?

TROUBLESHOOTING
D
IFFICULTIES
IN
T
EACHING
THE
M
ODEL
OF
E
MOTIONS

••
Example: “Can I have more than one emotion taking place at the same
time?”

••
Potential therapist reply: “Yes, you can. Sometimes you may experience more
than one emotion in response to the same prompting event. At times these emotions can be in confict with one another. Another possibility is that a secondary
emotional reaction comes in quickly in response to the primary emotion, making
things quite confusing and diffcult to separate. If you experience two or more emotions, just practice observing and describing each.”

MINDFULNESS OF YOUR CURRENT EMOTION

Therapists explain that applying core mindfulness skills in the service of accept—
ing one’s emotional experiences can reduce the suffering created from fghting,
resisting, judging, and/or rejecting them (or ruminating, amplifying, and holding
onto them). Because painful emotions are part of the human condition, everyone
has to face negative feelings such as hatred, fear, anger, disappointment, betrayal,
and jealousy—no matter how hard one might try not to. The trick is to fnd a way
of relating to these painful and diffcult feelings in a manner that does not increase
suffering.

Emotion Regulation Skills

Observing and Describing Emotions Homework Sheet
EMOTION NAME(S)
anger, frustration

Intensity
(0–100)
100

PROMPTING EVENT
for emotion (who, what, when, where):
Asked my husband to discuss how to pay for holiday gifts/trips this year. He refused to talk about it.

INTERPRETATIONS
(beliefs, assumptions, appraisals) of situation:
(1) He wants me to not bother him and just handle it myself.

(2) He is trying to upset me.

[Alternative Interpretation—He’s had a hard day at work & needed time to unwind. Not about me.]

BODY CHANGES and SENSING:
What am I feeling in my body?
Felt tense, upset stomach, headache, hot.

BODY LANGUAGE: What is my facial expression? Posture? Gestures?
Sat rigidly in chair not facing him, frown on face.

ACTION URGES: What do I feel like doing? What do I want to say?
I wanted to scream or throw something to shake him up.

What I SAID or DID
in the situation (Be specifc):
I cried, tried to make him understand my worries for 30 min, then stomped out.

What AFTEREFFECTS
does the emotion have on me (state of mind, other emotions,
thoughts, etc.)?

Upset, fushed, frustrated, felt like there is no resolution, want to binge.

FUNCTION OF EMOTION:

(1) Self-validation of my position (2) Got me to try to communicate the situation (3) Gets me to try
to fnd a solution

FIGURE 5.1.
Example of a completed Observing and Describing Emotions Homework Sheet.
Adapted from Linehan (1993b). Copyright 1993 by The Guilford Press. Adapted by permis—
sion.

Practicing the skill of Mindfulness of Your Current Emotion is a way clients
can let go of emotional suffering. The Observe and Describe skills, as well as the
skills of Nonjudgmentally and One-Mindfully, are very useful for helping to do
this. The goal, as therapists describe, is to note the emotion’s presence at the same
time that the client steps back from it and gets “unstuck.” Therapists remind clients that being mindful of the current emotion means being fully aware, open, and
present oriented. One accepts the entirety of one’s emotional experiences, rejecting
none of it. One permits the feelings without trying to change or “fx” them. Mindfulness of Your Current Emotion does not mean that one becomes
one’s emotion—
an important distinction. The therapist illustrates this by asking clients to imag-

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
ine their emotion as a raging river. If one jumps into the river, one can be carried
downstream by the rush of feeling. But if one remembers that it is possible to pause
and sit on the bank, one has the option of observing and describing the emotion
One-Mindfully and Nonjudgmentally. One can let the emotion rush by. In doing so,
the client is not trying to suppress, block, or push the emotion away nor attempting
to hold onto or amplify it.

Therapists might tell clients practicing this skill to specifcally remind them—
selves that they are not their emotion. In other words, when experiencing very
strong emotions, a client can remind him-or herself that this experience is not all
of who he or she is but is an experience stemming from his or her current state of
mind. Inevitably, all acute emotions pass. Therapists can illustrate this by asking
clients to think about emotions that dominated their thoughts at one point but no
longer do.

Mindfulness of Your Current Emotion is similar to the mindfulness skill of
Urge Surfng (Chapter 4) in that the client is riding an emotion’s wave and staying
with the emotional experience as it rises, crests, and falls—without fghting the
wave or trying to stop it. Use the following script (modifying as needed) to lead
clients in the related experiential exercise.

ExPERIENTIAL
Ex
ERCISE:
MINDFULNESS
OF
Y
OUR
C
URRENT
E
MOTION

“Take a moment to sit in your chair, feet on the foor, posture erect, breathing
slow, easy breaths from your diaphragm. Find a place for your eyes to focus, or let
them gently close. Then bring to mind a strong emotion that you have been aware
of recently. Maybe you were really hurt or angry? Or very sad? Whatever this
strong emotion, try to imagine letting go of the suffering by observing your emotion. Imagine stepping back from it, getting unstuck, and watching it. Experience
the emotion as a wave, letting it come and go just as waves crash to the shore on
the beach and then are pulled away. Do not try and block the wave. Do not try to
amplify it. Fully accept whatever is present without adding to it. Practice releas—
ing or unhanding the experience. Then take several deep fowing breaths and end
the exercise.”