Dialectical Behavior Therapy for Binge Eating and Bulimia (36 page)

Emotion Regulation Skills

choose to act opposite even though the anger is valid. Therapists should make sure
that clients do not mistake Acting Opposite for blocking, masking, or overdrama—
tizing emotions.

Instead of outright anger, many clients may be more familiar with experienc—
ing chronic irritability. This irritability may be justifed but still not effective, as
it can become self-perpetuating, leading others to be irritable in return and thus
maintaining the emotion. Acting Opposite means accepting the irritability and its
validity while choosing to act opposite to be more effective, such as by using gentle
words or a light tone.

Why Binge Eating (and Purging) Is Not Acting Opposite
Discuss with clients how binge eating or other problematic eating behaviors have
been attempts, albeit maladaptive, to use behaviors to change their experience of
distressing emotions. One reason that these behaviors do not work effectively is
that they do not involve Acting Opposite to the Current Emotion. Rather, they are
likely to be quite consistent with the emotion. For example, when clients feel angry,
binge eating (and purging) can be an expression of aggression, even if they are not
outwardly attacking anyone. When clients feel guilt or shame, the binge eating
(and purging) may express the urge to attack and punish themselves. Because the
binge eating (and purging) is more or less consistent with the current emotion,
these numbing or escaping behaviors serve to prolong the emotion rather than
change it.

Therapists express their sincere understanding that Acting Opposite to the
Current Emotion is extremely diffcult. But continuing to act as clients have been,
such as by binge eating and/or purging, reinforces clients’ negative emotions and
has debilitating consequences related to the behavior itself. Acting Opposite is an
incredibly powerful skill that will, in the long run, offer true help.

DISCUSSION
P
OINT: “Consider how practicing the skill of Acting Opposite to the Current
Emotion may replace your binge eating and other problem eating behaviors. When you
are depressed, for example, what might be the effect of getting active instead of spending the
day isolated and overeating and/or purging? How could you use opposite action when you are
in the throes of capitulating and believe you have no option except to turn to food?”

Therapists may wish to use the following experiential exercise to further illus—
trate the skill of Acting Opposite.

ExPERIENTIAL
Ex
ERCISE:
ACTING
O
PPOSITE

“Sit up straight, letting the chair fully support you. Take several deep, fowing
breaths in and out. Find a place for your eyes to focus. Then bring to mind a recent
situation in which you felt a strong negative emotion. Think about your reaction.
Was it consistent with your emotion? If so, what was the effect? For example, per—
haps you were depressed and you stayed in bed, or you were feeling hopeless and

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
overweight and started binge eating, or were angry and started yelling? Now, take
a moment to imagine that recent situation, validating the emotion but choosing to
act the opposite. Try to consider how you may feel different as a result.”

DISCUSSION
P
OINT: “Can you describe what you imagined and how Acting Opposite
affected your feelings?”

SUGGESTED
HOMEWORK
P
RACTICE

Remind clients that practicing the skills of observing and describing one’s current
emotion (e.g., using worksheets similar to Appendix 5.5) are essential to using the
skill of opposite action. Unless one frst accepts what she or he is feeling, she or
he cannot become aware of what actions would be opposite nor when taking such
actions would be effective. For example, observing and describing and increasing
awareness of one’s interpretations of events and body language associated with cer—
tain emotions may enable one to consider which opposite action to take to change
ineffective emotions.

1.
Therapists instruct clients to practice observing and describing a current
emotion and to complete the homework sheet (e.g., Appendix 5.5).

2.
Therapists instruct clients to think of ways to act opposite to their current
emotion when wanting to reduce or change their current emotional experience and
to write (e.g., at the bottom of Appendix 5.6) about what opposite actions were cho—
sen. Ideally, clients should practice Acting Opposite at least three times prior to the
next session.

MYTHS ABOUT EMOTIONS

The purpose of this section is to help clients challenge common myths about emotions. The Linehan Skills Manual Handout (1993b, p. 136), gives several examples
of such myths: “There is a right way to feel in every situation”; “Negative feelings
are bad and destructive”; and “If others do not approve of my feelings, I obviously
shouldn’t feel as I do.”

Ask clients to generate their own myths about emotion, perhaps the myths
that seem most linked with their binge eating (and purging) or myths they wrestle
with when practicing the Emotion Regulation skills. Suggest that clients take 5
minutes or so and write down their challenges to these myths.

A typical emotion myth described by clients with binge eating (and purging)
behaviors is “I won’t be able to stand feeling this [emotion].” Therapists may wish
to play devil’s advocate (using a playful tone) in helping struggling clients to challenge this myth, such as by replying, “Oh my gosh, yes, I can see that this emotion
is just killing you. Maybe we should get help, maybe call 911.” Taking a devil’s
advocate position in this situation may make it more likely that the client shifts
to a more dialectical view to effectively challenge her or his emotion myths (e.g.,

Emotion Regulation Skills

“Well, it’s not going to kill me, and actually I have been able to stand it. I’m hoping
with my new bag of tricks I’ll be able to manage these upsetting emotions more
effectively”).

SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to review their emotion myths and challenges
before the next session.

2.
Therapists instruct clients to increase their awareness of any other emotion
myths they hold that may not be effective. Are these related to the client’s urges to
binge eat (and purge)?

APPENDIx
5.1

List of Emotion Regulation Skills
••

Mindfulness of Your Current Emotion
••

Loving Your Emotions

••

Reducing Vulnerability to Emotion Mind
••

Building Positive Experiences

••

Mindfulness of Positive Experiences
••

Opposite-to-Emotion Action

From Dialectical Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice
Y. Chen. Copyright 2009 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers
of this book for personal use only (see copyright page for details).

APPENDIX 5.2

Model for Describing Emotions

Interpretation
of Event

Prompting
Event 1

Prompting
Event 2

Aftereffects

Adapted from Linehan (1993b). Copyright 1993 by The Guilford Press. Adapted with permission in Dialectical
Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice Y. Chen (2009).
Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright
page for details).

APPENDIx
5.3

Primary Emotions and Secondary Reactions Homework Sheet
Primary emotions involve your initial, gut-level emotional responses to events. Typical primary
emotions are love, joy, interest/excitement, fear, anger, and sadness. Primary thoughts,
sensations, and behaviors are frequently associated with primary emotions. For example, a
feeling such as excitement about an upcoming vacation may typically be accompanied by certain
thoughts
(e.g., “I can hardly wait for tomorrow!”),
sensations
(e.g., “butterfies in the stomach”),
and behaviors
(e.g., smiling).

Secondary reactions to the primary emotion usually involve judging the initial emotional
response. The consequence of this evaluative judgment is that the primary emotional response
is interrupted or halted, being replaced by secondary reactions. For example, in the preceding
illustration, a secondary reaction to feeling excited might be the feeling of guilt, such as the
thought “I shouldn’t be feeling so happy about vacation with my mother being ill; instead of going
I should spend my time off with her,” and sensations, such as experiencing a knot in the pit of
your stomach, slumping over, and so forth.

Instructions:

In the following space, write about at least one instance in which you noticed secondary reactions
to your primary emotions. Be detailed in your description, both of the primary emotion (with its
associated thoughts, behaviors, and sensations) and the secondary reactions. What were the
consequences of your secondary reactions—did you feel worse? Write about what you think
reinforces the secondary reactions.

From Dialectical Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice
Y. Chen. Copyright 2009 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers
of this book for personal use only (see copyright page for details).

APPENDIX 5.4