The holiday season is upon us. Therapists who have clients with binge eating disorder may usefully review the reasons why DBT-informed approaches can help those with eating disorders.
Related article: Assessing and Treating Eating Disorders.
Jump to section
Introduction
It’s that time of the year again: the bubbling joy of seeing friends and family; the vibrant, colourful displays in shops; and the overall sounds, sights, and vibes of goodwill that permeate the environment, at least for many in the western world. But the relaxing and “letting down of hair” during the holiday season brings with it a host of challenges for those with disordered eating. Getting together with family and friends is not an unalloyed delight for those who come from dysfunctional, invalidating environments. There is much induction to eat, drink, and spend too much in the hugely hyped-up social environments of the season. And time off work and/or away from home can be a recipe for disaster for those who depend on “normal” routines and structures to keep themselves from maladaptive behaviours around food.
Even people without a history of emotional eating can end up eating more, or more unwisely, than they intended during this period. For those with binge eating disorder or bulimia nervosa, the temptation to binge is likely to be overwhelming. In this article, we examine why – even if you are not a dialectical behaviour therapist – you may wish to review with clients the intimate connection between emotional dysregulation and disordered eating, sharing DBT-inspired understandings and strategies. We focus on BED (which does not include the purging/compensatory behaviours of bulimia nervosa) and exclude anorexia nervosa from consideration, as it is a different dynamic, perhaps more rightly called, “disordered non-eating”.
DBT is a therapy “made to order” for clients with emotional dysregulation, and we look first at the description of emotional eating and the statistics and health/impairment issues of BED, followed by DBT-informed strategies you can share with such clients to help them get through this period that can be so perilous for physical and mental health.
Characteristics of emotional eating
Jennifer Taitz, in her book about emotional eating defines it as: “a popular term used to describe eating that is influenced by emotions, both positive and negative” (Taitz, 2012, p22). Taitz explains that feelings may influence not only food choices, motivation to eat, and amount eaten. They also determine where and with whom a person eats and the speed of eating. While many obese individuals engage emotional eating, a person does not need to be overweight to be deemed to be doing it. Rather, it is about eating when not hungry to avoid experiencing an emotional process. Thus, examples of emotional eating include:
- A person snacking when not hungry/moderately full
- Experiencing an intense craving for a particular food
- Not feeling satiated after adequate amounts of healthy food
- Grabbing more food when one’s mouth is full
- Feeling emotionally relieved while eating
- Eating during or after a stressful experience
- Numbing feelings with food
- Eating alone to avoid others noticing (Taitz, 2012)
For a deeper dive on this topic, refer to the MHA course Intuitive Eating: Helping Clients Develop a Healthier Relationship with Food.
The stats, the health issues, and the impairment
We can note here that, even when eating-disordered clients have had some success in re-regulating their eating, the extra stress (including eustress) and high emotionality of the Christmas season may lead to relapses in behaviour toward “old” habits of using food to avoid emotions. Here are some BED statistics to put the importance of dealing with this issue in context.
The binge eating disorder statistics
Not surprisingly, BED is the most common eating disorder, with 2.8 million adults in the United States and 470,000 adults in Australia affected. The U.K. has about 270,000. BED is more prevalent than breast cancer, HIV, and schizophrenia. While the numbers are about 3.5% of women and 2% of men, they are 30-40% of people seeking weight loss treatments. 60% of those with BED are women, and 70% of those with BED are obese. However, only 43% of people with BED will seek treatment specific to that condition (Eating Disorders Victoria, 2019; Beat Eating Disorders, n.d.; Walden Behavioral Care, 2020; National Heart, Lung, and Blood Institute and NHLBI Obesity Education Initiative Expert Panel, 1998).
The health issues
The health risks ushered in by BED include anxiety, depression, a sense of worthlessness, heart disease, stroke, high blood pressure, high cholesterol, sleep apnoea, colon cancer, and breast cancer (Walden Behavioral Care, 2020; National Heart, Lung, and Blood Institute and NHLBI Obesity Education Initiative Expert Panel, 1998).
The work and personal impairment of BED
If the statistics and health issues aren’t provocative enough, consider these wide-ranging areas of impairment experienced by BED clients, compared to weight-matched controls without BED, in a study by Rieger and colleagues (2005):
- Interpersonal: 65.1% of those with BED versus 28.8% of obese controls without it believed that their relationships were impaired due to eating/weight issues and stress.
- Work: The same sense of impairment due to eating/weight issues and stress was experienced by 44% of those with BED, as opposed to 17.3% of weight-matched controls.
- Psychosocial: Those with BED felt impairment in areas such as asking for an increase in salary.
- Public activities: Those with BED were much more likely to worry about or have difficulties with public acts, such as fitting into a seat in a public area.
- Sex life: The BED, said BED-diagnosed participants, reduced sexual desire.
- Self-esteem: Those with BED had lower self-esteem than weight-matched controls without BED.
The study authors reiterated that, because the participants with and without BED were similar in terms of weight, the differences in results could not be attributed to levels of obesity (Rieger et al, 2005).
BED and emotion regulation
The reason for development of DBT programs (Linehan, 1993) adapted for BED and BN clients was because binge-eating and purging behaviours have been strongly suspected to be a response to emotional dysregulation. Let’s look at that briefly in the context of BED.
Multiple studies over the last several decades have homed in on the relationship between emotions, affect regulation, and BED. A recent summary review of the research findings on emotion regulation in Binge Eating Disorder (BED) found that negative emotions and maladaptive emotion regulation strategies play a role in the onset and maintenance of binge eating in BED. Anger and sadness, said the researchers, along with negative emotions related to interpersonal experiences (i.e., disappointment, being hurt or loneliness), seem to be particularly relevant. They concluded:
“Poor mood appears to precede binge-eating episodes and as is proposed by the theoretical models of BED, binge eating may be an attempt to down-regulate this emotional distress. Individuals with BED lack healthy and effective emotion regulation strategies, tending to suppress and ruminate on their unwanted emotions, which leads to increased psychopathological thoughts and symptoms. Compared to healthy controls, they use adaptive strategies, such as reappraisal, less frequently. Furthermore, their attempts to down-regulate their unwanted emotions may also lead to other unhealthy behaviors such as substance abuse and self-injury” (Dingemans, Danner, and Parks, 2017).
Why Dialectical Behavioural Therapy?
Putting together all this information, we can see the parallels with the original DBT for borderline clients. Emotional eaters, like borderline clients, seem vulnerable to emotional upset, both in perceiving situations as more stressful and in reacting with more emotional intensity, than do people without the disorders. They seem more prone to anxiety, depression, and other mood issues. Like borderline patients, they seem to have fewer than normal strategies for dealing with or regulating their emotions. And, like borderlines, they turn to short-term escape/avoidance strategies to seek relief. Where the borderline client self-harms or attempts suicide, the BED client engages an episode of binge eating. In both borderline and eating disorders, there is relief after the incident, but then a sense of guilt, shame, and worthlessness when the relief wears off, which sets up the individual to run around the cycle again, becoming more deeply entrenched in the maladaptive behaviours and – probably – more isolated from emotional supports that might help her escape the destructive cycle. And sadly, the time of year that has a high probability of triggering disordered eating is likely to be the holidays. Here are some strategies to help.
Strategies to reinvigorate commitment to ending bingeing
You may already be working with clients whose goal is to eliminate uncontrolled eating episodes. They may proactively ask to be reminded of strategies that they can use to shore up motivation and commitment to healthy eating over the holidays. You may also initiate enquiry as to whether such clients would find it useful to go over some tips for keeping on course with their goals for healthy eating and/or greater emotional regulation during the “silly season”. The interventions and strategies we identify here are excerpts of those introduced in the Mental Health Academy course Dialectical Behaviour Therapy for Eating Disorders, and most occur early in treatment. We include Pros and cons, 3 x 5 cards, Devil’s advocate, Foot-in-the-door, Door-in-the-face, Highlighting freedom to choose but absence of alternatives, and Cheerleading.
Pros and cons
You can (re-)introduce this skill by acknowledging that clients would not be there if they did not want to have a high-quality life, one with good relationships, a sense of mastery, and the ability to feel good about themselves most of the time. Binge-eating is a problem because it interferes with having a good quality of life, yet there are reasons that people turn to food. Thus, it makes sense to evaluate the pros and cons of continuing to be a binge-eater. You can then elicit reasons for and against the behaviour, writing down what clients say, starting with the “pull” to binge-eat, followed by the disadvantages of doing so. The questions can be: “What are the advantages to remaining a binger?” followed by “What are the disadvantages? What sorts of things are motivating you to think about this now?”
3 x 5 cards
A good follow-up to the verbal discussion is to have clients write the five best pros of abstaining from binge-eating on one side of a small card, with the other side devoted to the five worst consequences of binge-eating. They can be encouraged to read the card often to remind themselves why they are thinking about this now in the holiday period.
Devil’s advocate
Upon obtaining a good list of pros and cons for and against emotional eating, you can move onto use of the Devil’s advocate technique – that is, taking up the opposite position – as a way of cementing motivation behind a stance of stopping binge-eating. You might comment, for example, on how compelling the “pros” for continuing to binge-eat look and invite the client to convince you: “So, it’s a lot of work to give up binge-eating, especially now during the holidays when there is so much food around. Persuade me: why can’t a person continue to do it and have a high quality of life?” You would also clarify here that “quality of life” does not mean just getting through or barely surviving but feeling fully alive: living the best life that your client is capable of. In taking up the role of the devil’s advocate, you are drawing clients into the position that it is essential for them to stop bingeing to have the quality of life that most of them desire. This strategy works best when you continue to clarify and emphasise what you mean by “quality of life”, which is not an uncontrolled bash at the office Christmas party!
Foot-in-the-door
Here you get a small agreement (easier) first, and then follow it with a harder-to-do agreement. Some clients with BED may, for example, find it “impossible” to commit to never again having a binge episode. In this case, you may have to initially take less of a commitment, so it may be that the client agrees not to have any binge episodes until the next session, whereupon you can ask for another, perhaps larger, commitment to no-bingeing (say, several weeks, or until the end of the holiday season).
Door-in-the-face
With this technique, you make a more difficult request (say, eating no desserts whatsoever at all the holiday social gatherings), knowing that the client is likely to baulk, but then appear to concede ground, saying, “Ok, then, can you just do ___?” (something easier, such as limiting themselves to one dessert at each gathering). Relieved at “winning” a little and not having to do the whole thing, the client often agrees to the easier task.
Highlighting freedom to choose but absence of alternatives
To strengthen commitment, you may remind the client that they are free to choose not to take up either your recommendations or collaboratively generated plans, but highlight graphically the problems they have been trying (sometimes unsuccessfully) to manage on their own, followed by, “It’s your choice; what do you think?” If the low quality of life with disordered eating has been successfully explored with Pros and cons, client may indeed realise that their own efforts have yielded unhappy Januarys in the past after all the bingeing over the holidays. They may have health issues or desperately fear going backwards if they do not urgently take control of the issue now. Often, they do freely choose to commit at this point.
Cheerleading
The purpose of this technique is to generate hope, as many clients with disordered eating feel periodically hopeless to effect any change and decide to “give up”, particularly when they are anticipating the sheer force of Christmas eating traditions that they are about to encounter, on top of emotional encounters with family members. This involves reiterating to the client the qualities you see in them which lead you to believe that, over the holidays, they can indeed change – or maintain a change already in progress – to have a better life. You continue to “drag out” of the client the new, more adaptive, behaviours that you or they have observed. The intervention can go something like: “Well, you have managed to steer clear of binges before; what might help you to do it again at Christmas?” (Skills adapted from Rathus & Miller, 2015; Long, 2011; Safer et al, 2018 and 2009).
It may not be easy, but clients can learn to stop using food to avoid emotions – even over the holidays.
Key takeaways
- The holiday season may be particularly challenging for people with eating disorders because of the high emotionality, myriad inducements to overeat, and absence of normal routines and structures typical of the season.
- Eating disorders such as BED are characterised by emotional dysregulation typically made more severe by conditions encountered during the holidays.
- Whether you are a DBT therapist or not, you can use DBT strategies to help eating-disordered clients gain control of emotional eating.
- Interventions and techniques therapists can use to support clients include: Pros and cons, 3 x 5 cards, Devil’s advocate, Foot-in-the-door, Door-in-the-face, Highlighting freedom to choose but absence of alternatives, and Cheerleading.
References
- Beat Eating Disorders. (n.d.). Statistics for journalists. Beat Eating Disorders. Retrieved on 2 September, 2020, from: https://www.beateatingdisorders.org.uk/media-centre/eating-disorder-statistics
- Dingemans, A., Danner, U., & Parks, M. (2017). Emotion Regulation in Binge Eating Disorder: A Review. Nutrients, 9(11), 1274. https://doi.org/10.3390/nu9111274
- Eating Disorders Victoria. (2019). Key research and statistics. Eating Disorders Victoria. Retrieved on 2 September, 2020, from: https://www.eatingdisorders.org.au/eating-disorders-a-z/eating-disorder-statistics-and-key-research
- Linehan, M. (1993). Skills training manual for treating Borderline Personality Disorder. United States: Guilford Publications.
- Long, J. (2011). Dialectical behavior therapy (DBT) consultation for line staff working with adolescents in residential care. Ph.D. dissertation retrieved on 9 May, 2020, from Proquest data base: https://www.proquest.com/psychology/
- National Heart, Lung, and Blood Institute and NHLBI Obesity Education Initiative Expert Panel (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. Obesity Research 6(Supplement 2), s51-s209.
- Rathus, J.H., & Miller, A.L. (2015). DBT skills manual for adolescents. New York: The Guilford Press.
- Safer, S., Adler, S., & Masson, P.C. (2018). The DBT solution for emotional eating: A proven program to break the cycle of bingeing and out-of-control eating. New York: Guildford Press.
- Safer, C., Telch, C.F., & Chen, E.Y. (2009). Dialectical behaviour therapy for binge-eating and bulimia. New York, NY: The Guilford Press.
- Taitz, J.L. (2012). End emotional eating: Using dialectical behavior therapy skills to cope with difficult emotions and develop a healthy relationship to food. Oakland, California: New Harbinger Publications, Inc.
- Walden Behavioral Care. (2020). Binge-eating disorder. waldeneatingdisorders.com. Retrieved on 26 August, 2020, from: https://www.waldeneatingdisorders.com/what-we-treat/binge-eating-disorder/