Authors Debra L. Safer MD, Sarah Adler, PsyD, and Philip C. Masson, PhD, joined us for an interview on their new book, The DBT Solution for Emotional Eating: A Proven Program to Break the Cycle of Bingeing and Out of-Control Eating.
What follows are our questions in italics and their thoughtful responses.
Break the Cycle of Bingeing and Out of-Control Eating, you present DBT skills specifically because DBT tunes into the connection between emotions and binge eating. Can you please speak to this?
The book’s treatment model is based on the idea that binge eating is a learned behavior people turn to when experiencing unpleasant emotions because it helps them temporarily feel better. These emotions can be positive or negative. The problem is that the emotions never truly get dealt with and so they tend to reemerge. Also, binge eating itself is associated with serious physical and psychological consequences. We think that using binge eating to cope can be overridden by developing and practicing alternative skills for tolerating tough emotions instead of turning to food.
DBT skills were initially developed to specifically target managing the most overwhelming emotions that lead people to engage in problematic behaviors. The skills taught in this book have been adapted to target emotional eating as the primary problem behavior.
In the context of DBT and emotional eating recovery, why use “Diary Cards”?
Many people who engage in binge eating don’t start off with a great understanding of their emotions or the behaviors they engage in when responding to their unpleasant emotions. The Diary Cards prompt individuals to reflect on what emotions they are experiencing and this can often be the first step to working with them (it is hard to work with your emotions when you have no clue what emotions you are experiencing). Also, the Diary Cards encourage daily practice and reflection, a strategy that is often a key feature of any behaviorally-based intervention.
Can you please identify the steps in the behavioral chain analysis?
In a nutshell, the chain analysis is a tool to better understand the relationship between the emotions, thoughts, and behaviors that lead someone to binge eat, and other factors such as vulnerabilities, common triggers, and consequences. Basically, it’s a frame by frame snap-shot of how the binge eating happens and, subsequently, potential places where new skills can be applied. Often, when we end up doing something we later regret, we look at what was going on immediately before the problematic behavior. However, the factors that started us off on the path to engaging in the problematic behavior may have started many hours before. The chain analysis tool can be a wonderful strategy to develop self-compassion and gain much better insight into our behaviors and how to have better control over them. Learning how and why is so important to help “break the chain.”
You offer a summary and homework exercises at the end of each chapter. The homework exercises seem to offer gentle, focused directives for self-reflection and staying “with it.” What are some of the purposes of designing these exercises in this manner?
We acknowledge that stopping binge eating is a really hard thing to do. Reflecting on your emotions is a skill that helps individuals learn to accept their emotions rather than use food to cope. But, because these emotions are so tough to manage, and because often binge eating is the only coping strategy people have learned, adopting a non-judgmental stance towards oneself is fundamentally important to help people stay engaged when trying to break old patterns. We are modeling a “gentle” way to talk to the reader, because we have found that this population tends to be extremely harsh towards themselves and their binge eating. This can lead to urges to give-up and we want this experience to be different.
Please provide an example of black and white thinking and why this cognitive approach can be destructive?
In this population, people often think about binge eating in terms of success or failure. We hear people says things such as, “If I binge I have failed,” or “Once I start to binge the whole day is ruined and so I might as well eat whatever I want,” or “Success means never bingeing again.” We think that this is destructive because these types of “black and white” thoughts promote some of the difficult emotions (e.g., guilt and shame) that can trigger a binge and lead people to abandon the journey. A perfectionistic mindset doesn’t allow for the nuances that are needed to learn new skills. Alternatively, dialectical thinking allows you to have a goal and simultaneously not meet it, while continuing on the path of learning new skills. With dialectical thinking, there is never a need to give up because you aren’t doing things “right.”
You suggest the use of “urge surfing.” This term prompts an interesting visual. Please share a brief explanation of this skill.
The idea with urge surfing is that emotions resemble waves. Some waves are fairly small and it is very easy to tolerate them as they come up and then fall down. On the other hand, some waves can be very large. When you are in the midst of a large emotional wave you might not be able to see how it will ever go down. You might start to panic and do anything and everything to escape the wave. Urge surfing is about knowing that either small or large, emotions and urges will always come down and all one needs to do is ride it out. During the process of learning to stop binge eating people will have many urges to binge. The wave analogy allows the person to visualize themselves like a surfer on top of the wave, waiting until it carries your to shore, without giving in or getting pulled under.
What motivated you to coalesce your therapeutic practice skills and research evidence to develop this book?
Eating disorder specialists are really hard to find and there is a growing body of research that shows that many eating disorder specialists do not primarily use treatments that have evidence supporting their use. Even when skilled clinicians are available, people don’t always have the time or resources to get help. There were no self-help approaches that specifically target binge eating using a DBT emotion regulation model that had been tested in clinical trials. We hope to both reach people who don’t have access to care, as well as help ensure more treatments are available that are backed by evidence. This program can be used as either a self-help or guided self-help with a therapist. We also are hoping to have other researchers use this book as part of their trials to answer much needed questions about the program’s efficacy: For whom does a DBT approach work best? How does it work in a real world setting? Can it be effectively used in a group setting?
About the authors:
Debra L. Safer, MD, is Associate Professor of Psychiatry and Behavioral Sciences at Stanford University School of Medicine and Codirector of the Stanford Adult Eating and Weight Disorders Clinic. She is a coauthor of Dialectical Behavior Therapy for Binge Eating and Bulimia (for mental health professionals) and The DBT® Solution for Emotional Eating (for the general public). She has worked with hundreds of people with eating and weight concerns, with a particular focus on evidence-based treatment.
Sarah Adler, PsyD, is Clinical Assistant Professor of Psychiatry and Behavioral Sciences at Stanford University School of Medicine and a clinical psychologist in private practice.
Philip C. Masson, PhD, is on the Adjunct Clinical Psychology Faculty at Western University and is a psychologist practicing in London, Ontario, Canada.