Read an Excerpt
CHAPTER 1
The DBT Approach to Stopping Binge Eating
Over our many years working with patients we have found that stopping out-of-control eating is one of the hardest things most people will ever do. But don't worry: This program is all about teaching you that hard is not the same as impossible. It includes three important components:
1. The program starts by explaining why it's such a challenge to stop binge eating. Understanding what triggers a binge and what keeps you trapped in the binge-eating cycle can free you from judging yourself negatively, which actually thwarts your efforts to stop bingeing.
2. Then you'll learn skills and strategies for managing emotions without turning to food. By the end of this program you'll have a whole toolbox of skills to help you face problems instead of avoiding them, tackle them effectively instead of using the destructive approach of binge eating, and manage emotional distress when you encounter one of life's unsolvable problems. Our patients often tell us they think of the program's skills as a kind of "Emotions 101," or a basic life skills course they never had before.
3. The program uses dialectical thinking, which provides an alternative to rigid or "black-and-white" patterns that can keep you stuck. Dialectical thinking promotes more flexible thinking and allows you to embrace seemingly contradictory actions that help move you forward — accepting yourself as you are while simultaneously attempting to change, and using skills you already have while remaining open to learning the new ones taught in this program.
The DBT Emotion Regulation Model: Understanding the Link between Emotions and Binge Eating
You may or may not already be aware that you turn to extra food in response to emotional discomfort. The DBT emotion regulation model of binge eating (at the bottom of this page) helps explain how this response unfolds. Emotion regulation involves knowing what you're feeling and modulating your reaction to your emotional state or accepting and tolerating it when your emotions can't be changed immediately. According to the model, instead of regulating your emotions you turn to binge eating when your emotions feel too intense to modulate, tolerate, or otherwise manage — when you're emotionally dysregulated. Whether your emotions are "positive" (like happiness, excitement, desire), "negative" (like fury, disappointment, worry), or a combination, binge eating has become a learned behavior that serves the function of reducing your emotional distress. The good news is that a learned behavior can be un learned. (See the box on the facing page.)
Angela's Story
Angela was driving home late from work thinking about how her boss had criticized her report, leaving her hurt and angry. Brooding over how she hadn't gotten clear instructions or the appropriate appreciation for getting so much done alone, in so little time, she felt more and more resentful. As she spotted a fast-food restaurant, she found herself ordering two cheeseburgers, a milk shake, a large fries, and two apple pies. While eating, she stopped thinking about work or how angry she felt. Not too long after, however, she was flooded with disgust and shame. "How come I keep doing this to myself? Why can't I handle anything?" As the night went on she felt more and more furious with herself and increasingly devastated, hopeless, and angry, especially when she thought about having to go back to work the next day. Then she glimpsed her daughter's leftover birthday cake in the fridge and couldn't resist. "It's all too much," she said to herself. She finished the cake, feeling even more ashamed and an even deeper sense of despair. She went to sleep telling herself, "I HAVE to stop. This is crazy. What is wrong with me?"
Despite Angela's determination to stop binge eating, at her core she feels powerless to change because she doesn't truly understand why she's bingeing. We've filled in the DBT emotion regulation model for her first binge on the top of the facing page and for her second binge at the bottom to show not only what led to these binges but also what keeps her caught in this binge-eating cycle.
A: As shown for Angela's first binge, first something happens. At this point, Angela's binge eating may seem so automatic that she's not aware of anything setting it off — she just finds herself in the drive-through. But actually, there was a prompting (triggering) event (A), which can then lead to certain thoughts and feelings. Here the prompting event was criticism from Angela's boss, which led to the thought "My boss doesn't appreciate me. I'm never treated fairly" and the emotion of anger.
B: This next step is critical. The prompting or triggering event sets off an emotion (B) with which you don't feel able to cope. For Angela, it was feeling angrier and angrier at her boss's treatment of her. What types of emotions tend to be hard for you to cope with? Being bored when you are in the house alone might make you feel quite uncomfortable in and of itself. Also, being alone could set off more powerful emotions such as intense sadness, deprivation, or frustration. Even positive emotions like joy or desire can feel uncomfortable if you don't know how to manage their intensity. The idea here is that Angela has begun to experience an emotion that brings her discomfort.
Triggering events can be hard to identify, but essentially they are environmental prompts that start a chain reaction leading to binge eating. Here are a few examples:
Prompt: Catching a glimpse of your reflection. Thought: "I look so fat." Emotion: Shame.
Prompt: Your spouse flirting with an attractive stranger at a party. Thought: "He never looks at me that way anymore." Emotions: Sadness, jealousy.
Prompt: Cupcakes from your favorite bakery brought to the office for a birthday. Thought: "That would taste SOO good! It's not fair that I have to limit how much I eat!" Emotions: Resentment, sadness.
Prompt: Eating something off your food plan. Thought: "I've already blown it. I might as well keep going." Emotions: Resignation or hopelessness.
You may not recognize any of these as triggers when they arise. Even seemingly irrelevant events can become triggers when you're already vulnerable due to sleep deprivation, chronic stress, depression, and so forth.
C: Because intense emotions can be very difficult to deal with, it makes sense that Angela would try to reduce, avoid, or get rid of hers (C). People use a wide range of strategies to try to feel better, but Angela never learned the skills needed to monitor, evaluate, change, and accept intense emotional experiences.
D: This is why Angela decides to stop off at the fast-food drive-through. Food temporarily "solves" her problem, helping her numb out and forget about how angry her boss made her feel. Turning to food reduces her anger, sadness, frustration, loneliness, and any other uncomfortable feelings she has about her boss's actions.
E: But by the time she gets home, Angela begins to feel disgusted with herself and ashamed of her binge eating (E). When the emotions she escaped by binge eating start to creep back in along with the disgust and shame for turning to food, Angela feels even worse.
A: This is when she sees her daughter's birthday cake, which becomes the next prompting event (A) that perpetuates the cycle and sets off her second binge.
B: The uncomfortable emotions are the intense guilt and shame she feels about having turned to food.
C: To avoid or escape from the emotional discomfort, she is overcome with strong urges to take out the birthday cake.
D: She has her second binge, this time on the leftover cake.
E: Though temporarily numbed after eating the cake, by the end of the evening she is even more disgusted with herself and has an even deeper sense of hopelessness and despair.
She tries to feel better by promising to herself she "will never do this again." Unfortunately, this promise increases her vulnerability to her intense emotions because she is now depriving herself of the one strategy she had to feel better — eating. She has, in fact, set herself up to repeat the cycle.
Angela experienced an array of intense and uncomfortable emotions. She may, as many people do, believe that her feelings are the problem — they are too much, too intense, there is something wrong with her. (As it turns out, people with binge-eating problems may very well be born experiencing emotions more intensely than others, and they may also believe it is inappropriate to experience certain emotions, such as anger. We will discuss this more a little later in this chapter.) However, we believe it's not Angela's feelings that are the problem. Angela's uncomfortable emotions make sense given the situation. When treated unfairly, she feels bad. We believe the problem is the behavior or strategy (binge eating) she is using to cope with her emotions. In the short run, it helps her feel better, but in the long run, her behaviors around food seriously impair her quality of life, leading to more distress, more misery, and more out-of-control eating. Because she doesn't think she has the tools she needs to identify and solve her underlying problem, she gets caught in a vicious cycle that involves not only increasing reliance on binge eating to temporarily manage emotional discomfort but also isolation and a reduced chance of receiving validation, help, and support. Numbing emotions with food interferes with developing healthy behaviors that may lead to true improvements in your life.
What if you aren't sure whether your emotions are driving your overeating? Maybe you think to yourself, "I just really love eating" or "I just eat when I'm bored." Or maybe you don't know why you overeat. Let's look at John's experience.
John's Story
John is a busy executive with multiple business dinners a week. When he gets home, he sits down on the sofa and turns on the TV. He doesn't feel hungry ("I just ate a big dinner"), but the next thing he knows he is grabbing a pint of ice cream and a spoon. He came to us for help with what he views as an irrational, distressing habit. "Why are you eating?" he demanded of himself. "There's no reason to eat this much. How can you be able to control other things but be such a failure at controlling your eating?"
The DBT emotion regulation model helped John see that binge eating might be more than just an "irrational habit" for him. Recalling that his father had responded to any expression of negative or painful emotions with angry demands to "Stop complaining!" John joked that the only time you were "allowed to complain was if you were so ill you needed to go to the hospital." Because he was motivated to gain control over his binge eating, John was open to the idea that his emotions might be linked to his binge eating. He started paying more attention to what was going on inside of him when he binged. After his most recent binge on ice cream after a business dinner, he was able to break down his "irrational habit" as follows (see page 24).
A: Prompting event: sitting on the sofa with the remote control.
B: There he noticed that his body and mind felt restless — "not wanting to go to bed but not quite knowing what to do with my energy." Internally, he was saying to himself: "I need something, I need something, I need something." As we encouraged him to try to come up with emotion words, he said: "Frustrated. I'm annoyed and frustrated. I spend every waking hour at work or at these work dinners. I come home and go to sleep, and then I start all over again." We asked John if perhaps when he said he "needed something" he could be feeling that work alone wasn't enough. He said that might be true, but it was hard for him to know for sure.
C: John goes to the freezer and takes out the ice cream. His first swallows of ice cream taste delicious, distracting him from his distress. This leads him to continue to eat, although he tells himself harshly to stop.
D: Ultimately, he ends up binge eating the ice cream. In the short run, the binge allows him to numb himself from the discomfort of restlessness, annoyance, frustration, and other emotions, potentially including feeling empty or lonely.
E: However, lying uncomfortably full on the sofa for the rest of the evening, it doesn't take long for him to feel disappointed, angry, and disgusted with himself for losing control yet again.
Not all of our patients describe their difficulties with food in the same way as Angela and John. Leticia, for example, is certain her difficulty is that she just loves food "too much" and can't limit herself, especially if tempted by certain types of foods like carbohydrates.
Leticia's Story
Leticia had been following her "New Year's" diet, the latest in a lifelong series of diets, and was feeling dedicated to finally getting herself into shape. On this particular day, she was able to eat healthfully and moderately because she planned to go to her mother's home for a family get-together. She decided in advance that she would eat only tiny portions of her mother's specialties, but when she got to the house she found the aroma of the homemade food overwhelming. Once she took her first bite she was overcome with the desire to take a larger serving. Then, recognizing that she had broken her diet despite her resolve and all the hard work and exercise she had invested, she was filled with shame and disappointment. She thought to herself: "I've already blown it. The damage is done. I might as well binge all the way so I can start over tomorrow." She thus ate everything she wanted, including extra sweet potato pie. Initially, this resulted in an almost trancelike state in which all she focused on was the sensation of the food. Eventually she felt overly full and completely demoralized. At her next therapy session, when describing the episode, she didn't think she had been experiencing any identifiable emotions before she went to her mother's home and couldn't see how the DBT emotion regulation model applied to her.
We explained to Leticia that we had worked with many patients like her and agreed that the emotion that led her to binge was not present before she went to her mother's home.
A: Prompting event: the smell, sight, and taste of her mother's home cooking (see below).
B: Emotion: intense desire triggered by eating the food. Leticia experienced her desire as almost unbearable, because Leticia was apparently a hedonic eater, someone whose brain is wired to be highly sensitive to food with or without physical hunger (more on this below). Setting a limit or boundary with herself, especially after she had crossed the one she first set, felt emotionally impossible. This dynamic is explained by the DBT biosocial theory, which we will discuss later in this chapter in detail.
C: Breaking her diet triggered self-criticism, disappointment, and shame and led Leticia to put more food on her plate to try to avoid these emotions.
D: She then gave in to her urges and binged on everything she wanted to eat.
E: Temporarily this led to a reduction in her emotional discomfort, but in the long run it resulted in disappointment, self-criticism, and demoralization.
Leticia now understood desire to be the initial emotion she found so hard to tolerate, so the DBT emotion regulation model seemed to fit her experience. But if she couldn't blame herself and her lack of self-control, she could only blame her brain and biochemistry. Didn't that imply, she worried, that her situation was hopeless?
We don't believe that at all. We teach the DBT biosocial theory because, in our experience, it explains why some people have more difficulty tolerating emotional distress than others and it can help them be more compassionate and patient with themselves. If you recognize yourself as one of those people, you will understand just why the skills taught in this program will be so transformative for you.
We'll delve into the DBT biosocial theory in a minute, but first, think about whether the model of emotion regulation reflects your own experience with binge eating.
(Continues…)
Excerpted from "The DBT Solution for Emotional Eating"
by .
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