Dialectical Behavior Therapy for Binge Eating and Bulimia (32 page)

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to practice being mindful of their current emotion by
using the Mindfulness “What” skills of Observe and Describe and the “How” skills
of Nonjudgmentally and One-Mindfully.

Loving Your Emotions
Therapists introduce this new skill by reminding clients that the Mindfulness
skills leave the door open for all of the client’s experiences. They allow awareness

Emotion Regulation Skills

without judgment or condemnation. With acceptance, the client is allowed a “pure”
experience. He or she may have pain but does not add to it the extra baggage that
results when he or she fghts or resists the emotion. Although it is absolutely natu—
ral to want as little pain as possible, according to the research-supported view
described, attempts to suppress or avoid pain simply add to the suffering and dis—
tress one experiences.

Therapists may fnd it helpful to illustrate this concept by having clients recall
the Chinese straw “fnger puzzle” (en.wikipedia.org/wiki/Chinese_fnger_trap).
The puzzle teaches that fghting to get your fngers out from both ends of a straw
cylinder ensures that you stay locked in a struggle, whereas letting go and ceasing
to pull on your fngers releases you from the puzzle trap. Therapists might also
describe a monkey trap that uses no restraints or clamps. The trap contains a hole
through which the monkey can reach a banana. The hole is just large enough for a
monkey’s arm, but not for both a monkey’s arm and
a banana. By being unwilling
to release its grip on the banana, the monkey is not able to free its arm and thus is
trapped. But as soon as a monkey accepts the reality of the situation and its limits
by releasing the banana, the monkey is no longer stuck.

The story of the ugly duckling, with its message of accepting who one is
rather than trying to be someone else, is also relevant. Just like the ugly duckling that turned out to be a swan, all of a client’s emotions are part of her or his
experience. Some might seem ugly to the client, others beautiful. But there can
be some meaning and wisdom even in those emotions that seem like “ugly ducklings.” Similarly, the skill of acceptance allows clients to observe and describe
their emotion, radically accepting its presence instead of using food to try to
avoid experiencing it.

Therapists will fnd it helpful to acknowledge that radically accepting, let alone
loving, one’s emotions is likely one of the hardest skills for clients with eating dis—
orders to practice. The word “loving” often raises judgments that therapists should
encourage clients to vocalize. Initially, clients may fnd it easier to practice radical
acceptance of their emotions. This acceptance is not a superfcial one but a very
deep, internal, Wise Mind acceptance of one’s emotion.

It is important to convey understanding of how hard it is for many clients
to let go of trying to control their feelings, emphasizing that this skill requires
a great deal of practice. Also make clear that clients who do learn should fnd
themselves able to focus their energy more productively. Therapists might offer
the metaphor of having a leak in the oil pan of your car. One option in that situation is to spend all your energy thinking about how much you are suffering by
having to continually check the oil level and purchase new oil. Therapists ask
whether clients are able to recognize that staying engaged in the struggle is
actually a distraction from thinking about the larger issues of why one has the
oil leak in the frst place or how to go about fxing it. Thinking about the cause
of the problem or how to solve it is also not pleasant, but it is likely to be a much
more effective strategy.

Following is a script for an experiential exercise illustrating this skill that we
have used in our groups (to be modifed as needed).

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
ExPERIENTIAL
Ex
ERCISE:

LOVING/RADICALLY
A
CCEPTING
Y
OUR
E
MOTION

“Begin by sitting comfortably in your chair, letting it fully support you. Keep your
spine straight, head up, and fnd a place for your eyes to focus. Take a few deep
fowing breaths, in and out. Then practice radical acceptance of who you are and
of your emotional experience. Practice not judging but allowing yourself to accept
whatever is there, even if it is painful and you wish you did not feel it. Let it be
just what it is. Do this while breathing in and out for ten breaths. Then end the
exercise.”

DISCUSSION
P
OINT: “What do you think about radically accepting your emotions,
being willing to be open to all of your feelings? Which emotions are you not accepting?
Can you think of a time when radical acceptance of your emotion has reduced your level of
suffering?”

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to practice letting go of emotional suffering by radically
accepting their emotions. Clients should track their practice of this skill on their
diary cards.

FUNCTION OF EMOTIONS

Introduce this section by explaining that evidence pointing to the important function that emotions serve is their presence beginning at birth. Crying, frowning,
trembling, and laughing are hardwired, so to speak, into our nervous systems. One
cannot just get rid of them.

Acknowledge that because emotions are functional to the individual, changing
binge eating (and purging) behaviors can be very diffcult, especially when such
behaviors serve important communication purposes and/or provide a sense of tem—
porary relief. It is therefore especially important for a client to understand how her
or his emotions function, as this knowledge can help her or him be more effective at
changing the emotion or her or his responses to it. This is a key reason clients will
be learning about the function of their emotions in this session.

Therapists explain that emotions and emotional behavior generally serve the
following purposes: (1) to communicate to others and infuence their behavior, (2)
to organize and motivate the client’s own behavior, and (3) to validate the client’s
own perceptions and interpretation of events. Each is discussed in turn.

Emotions Communicate and Infuence Others
Therapists describe how the expressive characteristics of emotion in the client’s
voice, face, gestures, posture, and words serve the essential function of commu-

Emotion Regulation Skills

nicating his or her emotional state to others. The value in these communications
is both that it allows others to know how he or she feels and that it infuences
the behavior of others. The facial expressions and gestures linked with one’s emotions communicate information very rapidly. Compared with words, emotions can
be faster, more powerful, and more effective at infuencing others, such as when a
person’s terrifed face signals a panic or a baby’s sharp cry calls forth the attention
and nurturance of its caregiver.

When nonverbal expressions, such as posture and facial expressions, do not
match what a person states verbally, others usually will trust the person’s nonverbal expressions over his or her verbal ones. This “mismatched” communication can
be very confusing, however, for both the sender and the receiver of the communication. For example, if a client verbally insists, “No, I’m fne, nothing is bothering me”
when her or his facial muscles are tense and body slumped, others may be aware
that something is wrong but may interpret the client’s verbal message as indicat—
ing that she or he wishes to be left alone. This may lead them to change the subject
and collude with the client’s statement that nothing is wrong—potentially leading
the client’s emotional experience to a greater intensity (e.g., feeling more hurt and
uncared for).

The therapist points out that because communication is an essential function
of emotions, it can be very hard for clients to change an emotional experience until
the communication has been accomplished. Thus one means of changing an emotion is to communicate with a person who is receptive, allowing time for the intensity of the emotion to diminish.

Therapists will fnd it useful to point out to clients that whether or not it is
intentional, their emotions will infuence others. The more aware a client is of what
she or he is feeling, the more direct her or his communication can be.

Emotions Organize and Motivate for Action

Another chief function of emotion is to organize and motivate the client’s behavior—
to get her or him to run, hide, cling, fght, and so forth. This function has survival
value and is an important reason that therapists are not suggesting that clients
attempt to rid themselves of all emotion! Fear, for example, may keep clients from
engaging in acts that are dangerous. The threat of shame may keep clients from
behaving in ways that could risk their losing the attachment of signifcant others.

Emotions have the capacity to activate certain behaviors within us in which
we otherwise might not engage. For example, fear can cause the brave to cower, or
anger may drive the pacifst to fght.

DISCUSSION
P
OINT: “Can you think of any current examples of emotions (e.g., anger,
excitement, shame, guilt, fear) that may be functioning to organize you, prepare you,
and/ or motivate your actions?”

Therapists consider with clients how binge eating (and purging) interferes with
the organizing, preparing, and motivating function of their emotions. For example,
a client might imagine having an argument with a friend or spouse, after which

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
she or he felt sad and experienced regret. Such emotions might motivate the client
to communicate an apology or to fnd some means of repairing the rift. If, instead,
the client turns to food to suppress her or his sadness and guilt and subsequently
withdraws, the function of communicating an apology is interfered with, and the
client may ultimately feel even worse.

DISCUSSION
P
OINT: “In what way do you think binge eating and/or purging interferes
with your ability to effectively manage your emotions?”

Emotions Communicate to Ourselves

Therapists describe another function of emotions: to communicate information to
ourselves. A client’s emotional reactions, including his or her “gut” response or
intuition about a situation, can give him or her invaluable knowledge. Emotions
can act as signals and sometimes even alarms.

Although emotions can usefully support a client’s reactions, clients must also
be made aware of the possible inaccurate infuence of emotions as an information
source. In other words, the client might depend solely on her or his Emotion Mind
reasoning when assessing or reacting to a situation instead of taking into account
her or his Reasonable Mind reasoning. One explanation for this tendency involves
the ongoing infuence of the past on the present, as brought up earlier. A client
whose parent was afraid of spiders, for example, might grow up thinking all spiders are dangerous—even though most are harmless. In such a case, if the client
reacts with panic when she or he sees a spider, this panic communicates to her or
him the potential of danger but would not necessarily be accurate for the situation.
In other words, the client is using her or his emotions to confrm what her or his
Emotion Mind is telling her or him, instead of searching for a fuller Wise Mind
understanding.

Many instinctive anxiety and fear reactions stem from this ongoing emotional
infuence of the past on the present. For example, if someone does not say hello
to a person when passing him or her on the street, it would not necessarily be a
cause for alarm in and of itself. But if the person has a history of being ignored
by his or her parents, he or she might interpret a current situation as a signal of
being unlovable. His or her emotions can still serve a useful function as long as
the person recognizes that in such cases his or her emotions are communicating
about the past rather than the present. Indeed, recognizing the way in which our
emotions communicate information regarding how we feel about the past can help
us understand why certain intense emotions can be triggered by seemingly trivial
prompting events.