Dialectical Behavior Therapy for Binge Eating and Bulimia (35 page)

DISCUSSION
P
OINT: “Are you someone who makes time for pleasant events but limits
the potential to derive enjoyment from your activities by engaging in self-criticism, guilt,
and worry?”

SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to consider positive feelings they would like to
increase (e.g., pride, joy, love) and to identify ways in which their secondary reac—
tions may be interfering with deriving full enjoyment.

2.
Therapists instruct clients to practice attending to positive experiences
and refocusing their attention when worries or other secondary emotions intrude.
Therapists might say, “All emotions come and go, including positive emotional experiences. The idea is to not destroy or distract oneself from the positive emotions
before they have had a chance to fully exist.”

3.
Therapists instruct clients to set up specifc goals for the different guide—
lines intended to increase positive emotions (e.g., attending to relationships, avoid
avoiding, building mastery). Using a homework sheet (e.g., Appendix 5.6), clients
should write down a specifc frst small step (or series of small steps) they could
take during the following week to work on achieving these goals. Their progress
should be tracked.

The following suggested questions may be asked to check on homework related
to reducing emotional vulnerability:
••

••

••

“Did making specifc behavioral changes help reduce your vulnerability to
emotion mind and to problem eating?”

“What was the effect of increasing positive events, both in the short run and
longer term? How did practicing mindfulness of your positive experiences
infuence your sense of emotional vulnerability?”

“What would you identify as your strengths and weaknesses in these areas?
How can you reduce your areas of weakness by positive endeavors?”

ACTING OPPOSITE TO THE CURRENT EMOTION

The goal of learning this skill is to be able to change or regulate one’s emotions
by acting in a way that is opposite to one’s current emotion. Acquisition of this
skill offers clients a very powerful means of changing their emotions over the long
term.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

Therapists make clear that the very frst question to address when practicing this skill is whether a person wants to change his or her emotion. The skill of
acting opposite to an emotion is not intended to be used when an emotion is adaptive and justifed. Rather, it is for instances in which an emotion is ineffective and
getting in the way of experiencing one’s desired quality of life. As was described
earlier, certain emotions may not be justifed in the sense that they do not ft the
facts of one’s situation. A client’s fear of air travel, for example, may be out of pro—
portion to the actual danger of fying and may interfere with important life goals,
such as keeping in touch with family and friends in other parts of the country or
the world. Or an emotion is justifed but its presence or intensity may be ineffective
or maladaptive for one’s circumstances. At such times, it may be effective for clients
to change their emotions.

Therapists review with clients that there are many skillful ways to change an
emotional experience, including considering alternative interpretations, thinking
about the function of one’s emotion, and so forth. Acting Opposite to a Current
Emotion is a behaviorally based skill for changing one’s emotional experience. Acting Opposite is not the same as “masking” one’s emotion or covering it over. One
can validate one’s emotions while making a Wise Mind decision to act opposite to
them.

A next step is for clients to identify the natural action behavior associated with
the emotion they wish to change. The action to take is then to behave opposite to
that natural action urge. The natural action behavior associated with the emotion
of fear, for example, is to attempt to escape or avoid. To change the emotion of fear,
clients must do the opposite of running away; they must approach. To overcome
the fear of airplane travel, for example, clients must fy on planes—over
and
over
and over.

Therapists highlight two important tips for applying the skill of Acting Opposite to the Current Emotion. First of all, as cannot be overemphasized, clients
should use this skill only for emotions that are interfering with their desired quality of life (i.e., are not effective). The client would not employ Acting Opposite when
encountering a justifed fear that is adaptive for a dangerous situation.

Second, clients must remember that Acting Opposite to the Current Emotion
will not provide an immediate emotional change. Indeed, the intensity of one’s emotion will, in the short term, increase. For example, if clients are phobic about spiders
and begin acting opposite and approaching arachnids, the emotions of anxiety and
fear will spike at frst. The fastest way to reduce fear and anxiety is by avoiding
spiders. But, as therapists caution, avoidance acts to strengthen the fear response
because essentially one is telling oneself that one’s interpretation of danger when
encountering spiders is correct. Avoidance makes it more likely in subsequent situ—
ations that one will experience fear. Research in this area has demonstrated that,
in the long term, acting opposite to emotions of fear, depression, and anxiety is an
effective strategy. The emotions do
change.

Underscore that practicing Acting Opposite to the Current Emotion is not a
quick-fx skill that yields results immediately or that will work despite being practiced only once or even a few times. Particularly when trying to change very intense
or well-established emotions, repetition is key. Beginning with the frst time clients act opposite, their brain begins processing new information. On that level,

Emotion Regulation Skills

change is taking place right away, but time is required to enable that initial brain
processing to change the emotion the client experiences. It is vital for clients to be
prepared so as not to be unrealistic and risk becoming too easily discouraged.

Furthermore, important in the success of Acting Opposite is not only repetition
but also full participation in Acting Opposite (Acting Opposite all the way). This
requires both physically engaging in the action that is opposite to the urge and also
altering one’s thoughts (e.g., judgments). In other words, practicing opposite action
also involves Acting Opposite with thoughts and nonverbal behaviors.

Review with clients what Acting Opposite entails for each of the basic emotions.

Fear

Acting Opposite to fear means approaching the feared situation over and over and
over. When fear is overwhelmingly intense, clients should attempt to divide the
feared tasks into a series of smaller steps. Then clients would approach the frst
step on the list, then the second, and so forth. For example, a client with a fear of
air travel might break down Acting Opposite by frst going to an airport to sit and
watch the planes take off and arrive. The therapist emphasizes that approaching,
small step by small step, what feels overwhelming will ultimately give clients a
sense of control and mastery.

Therapists might ask clients to think about things that make them anxious
(e.g., asking for help, accepting help when offered) and take steps to approach
rather than give in to those fears.

Guilt and Shame

It is important to help clients distinguish between justifed versus unjustifed guilt
and shame, as these are treated differently. Explain that guilt and shame are
justifed when a client’s actions violate her or his core Wise Mind values. If clients
engage in cheating and if guilt and shame ft their Wise Mind values, repair is
the solution to changing the emotion. Clients will likely need to consult their Wise
Mind to gain clarity about what this repair involves. To change the emotion of
justifed guilt and shame, therefore, clients must acknowledge that their behavior
violated their values and must repair the damage, accept the consequences, and
fnally forgive themselves and move on.

Therapists emphasize that
accepting the consequences of one’s action does
not mean judging oneself as bad. It is an unavoidable fact of life that everyone
makes mistakes and does things they wish they had not done. Clients often become
“stuck” in guilt and shame because they are afraid that admitting to wrongdoing
and repairing the transgression would mean having to hate themselves. Accepting
consequences can be very freeing if it can be done without judgment.

When clients’ behaviors do not violate their core Wise Mind values, the emotions of guilt and shame are probably unjustifed. Likely, these emotions are based
on fear. For example, clients who experience guilt and shame when saying no to a
request are likely reacting to the emotion of fear—fear that protecting their self—
interests will result in rejection or retaliation. Here, instead of engaging in repair,

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
opposite actions to reduce guilt and shame involve doing what one feels guilty or
ashamed of over and over (e.g., learning to say no without excessive apologizing,
guilt, or shame).

Sadness or Depression

Therapists explain that the natural behavior in response to despondency is to withdraw, becoming inactive and lethargic. Effective treatments for depression involve
clients doing the opposite of these behaviors, such as getting out and being active,
approaching, and doing things that make them feel competent and confdent. This
involves socializing with others, scheduling and getting involved in activities, and
so forth.

The trap that many clients fall into, especially with the emotion of depression,
is wanting to feel happier and more motivated before making a behavioral change,
saying to themselves, “I want to feel like going out and being with friends frst, and
then I’ll do it.” Point out how this strategy backfres when clients act on what the
emotion urges them to do, such as an urge to withdraw when depressed. With the
emotion strengthened, clients are further ensnared in their depression.

Therapists might fnd it useful to emphasize that starting an opposite action
behavior, such as exercise, especially for clients who are depressed, may not help
them feel better immediately and may, in fact, make them feel worse. As discussed,
this is what would be expected. Therapists can reassure clients that opposite
behaviors do communicate a new and different message to the brain and that their
brains are
processing these but that time is required to translate these messages
into emotional changes. One may not feel at all like socializing and being with others but must act “opposite” so that, slowly, positive emotional changes will follow.
In summary, to change the emotion of sadness, clients must do the opposite of this
emotion’s action urge and become active.

Anger

The natural behavior associated with anger is to attack and hurt others. To change
or reduce anger, therefore, clients must do the opposite. This may involve “taking
a break” from the person a client is angry at (if she or he feels unable to communicate with that person without attacking) until she or he cools off. Acting Opposite
may also involve doing something kind for the other person or putting oneself in
the other person’s shoes. Similar to avoiding reparations when feeling guilty, many
clients are unwilling to act opposite to their anger out of the belief that being kind
or having empathy for the other person would mean admitting to wrongdoing or
necessitate judging oneself as bad.

It may be useful to emphasize that clients are choosing to change their anger,
as well as their expressions of anger, only in cases in which that emotion is destruc—
tive and ineffective for achieving their goals. Remind clients that anger (or any
emotion), whether justifed or not, is valid. Past experiences may have understand—
ably infuenced clients to feel as they do. One of the key functions of anger may
be to communicate to oneself that one has a right to be angry. However, if clients
decide that it is not useful or effective for them to be angry to this degree, they may