Treatment of Eating Disorders by Emotion Regulation - Valerija Sipos - ebook

Treatment of Eating Disorders by Emotion Regulation ebook

Valerija Sipos



Eating disorders belong to the leading causes of lost life years in young adult women. Current behavioral treatments are efficacious but reach only part of the affected women. The treatment presented in this book differs from many prior treatment approaches in that it assumes that disturbed eating behavior is a consequence of difficulties in emotion regulation. It focuses on imparting skills that improve self-management, foster mindful and healthy eating behavior, emotion regulation, social skills and distress tolerance. "Treatment of Eating Disorders by Emotion Regulation" has a modular structure and is designed for use as the basis for inpatient and outpatient treatment and besides that has a self-help manual. It contains a plenty of psychoeducational materials, work sheets, case vignettes and background information for therapists.

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Valerija Sipos, Ulrich Schweiger

Treatment of Eating Disorders by Emotion Regulation

W. Kohlhammer

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1. Edition 2017

All rights reserved

copyright © 2017 by W. Kohlhammer GmbH, Stuttgart

Production: W. Kohlhammer GmbH, Stuttgart


pdf:       ISBN 978-3-17-033022-1

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This book is dedicated to the Venerable Ayya Khema. She taught us the principles of mindfulness. Our encounter with her had a huge impact on the paths we chose in our life.

Table of contents






Handling of the manual

Part 1

1 Symptoms of the eating disorder module

1.1 Who is this manual for?

1.2 Symptoms of an eating disorder

2 Self-management tools module

2.1 Why is this module important?

2.2 What does a dialectical approach imply?

2.3 What does changing yourself mean?

2.4 Values and goals

2.5 Learning to plan

2.6 Learn how to deal with dialectical dilemmas

2.7 Learning Theory

2.8 Commitment

2.9 Keep a food diary

2.10 Learn chain analysis

2.11 Learn Behavioural Analysis

2.12 Application of the chain analysis and the behavioural analysis

3 Module for mindfulness and acceptance

3.1 How can mindfulness be practiced?

3.2 Learn mindfulness exercises

3.3 Steering mindfulness towards eating behaviour

3.4 Application of mindfulness within the “treatment of eating disorders by emotion regulation”

3.5 Learn validation strategies

3.6 Radical Acceptance

3.7 Application of validation and radical acceptance

4 Module for healthy eating behaviour

4.1 Why is this module important?

4.2 Why healthy eating is important for emotional stability?

4.3 Nutritional knowledge

4.4 Normalisation of exercise behaviour

4.5 Elimination of interfering factors for healthy eating

5 Module dealing with emotions

5.1 Why this module is important?

5.2 What can you learn?

5.3 What we know about emotions?

5.4 Mindfulness of emotions

5.5 Influencing of emotions

5.6 Avoid emotions?

5.7 Accept emotions without changing them

5.8 Act with or opposite to your emotions?

5.9 Compassion

5.10 Things to know about major emotions

5.11 Reduce emotional lability

5.12 Application of the module “Dealing with emotions” in the treatment of eating disorders through emotion regulation

6 Interpersonal skills module

6.1 Why is this module important?

6.2 You can practice in the following areas and situations

6.3 What do we know about interpersonal skills?

6.4 How do interpersonal skills benefit you?

6.5 Planning of interpersonal situations

6.6 How can you practice interpersonal skills?

6.7 Insecure and aggressive behaviour

6.8 Damaging relationships

6.9 Conflict management strategies

6.10 Learning from problematic encounters

7 Module for stress tolerance

7.1 Principles underlying the application of stress tolerance skills

7.2 Psychological tension

7.3 Physical exercise for increasing stress tolerance

7.4 Thermal stimuli for increasing stress tolerance

7.5 Acoustic stimuli to increase stress tolerance

7.6 Taste and odour stimuli for increasing stress tolerance

7.7 Difficulties in the application of stress tolerance skills

7.8 Distract yourself from problem behaviour

7.9 Behavioural activation

7.10 List of activities

7.11 Imagination of a safe place

7.12 Contingency plan

7.13 Application of stress tolerance skills within the scope of treating eating disorders through emotion regulation

8 Implementation of the manual in different settings

8.1 Inpatient or intensive outpatient psychotherapeutic programme

8.2 Outpatient individual therapy

Part 2 Characteristics of severely ill patients with eating disorders

1 Anorexia nervosa, borderline personality disorder and histrionic personality disorder

1.1 Anorexia nervosa with extreme underweight, major depression, obsessive compulsive disorder, post-traumatic stress disorder and borderline personality disorder

1.2 Bulimia nervosa, major depression, social phobia, borderline personality disorder and schizotypal personality disorder

1.3 Binge-eating disorder, borderline personality disorder and social phobia

1.4 Binge-eating disorder, borderline personality disorder, cannabis dependence and alcohol abuse

2 The rationale for choosing emotion regulation as a starting point for treating eating disorders

2.1 Emotion regulation and eating disorders: empirical findings

3 Theoretical foundations of treatment

3.1 Attitude of the therapist

3.2 Formulation of the framework of the therapy

3.3 Therapeutic Techniques

4 Information for therapists regarding the modules

4.1 Module for eating disorder symptoms

4.2 Module for self-management tools

4.3 Mindfulness and acceptance

4.4 Module for healthy eating behaviour

4.5 Module for emotion management

4.6 Module for interpersonal skills

4.7 Stress tolerance skills

5 Eating disorder - Basic knowledge for the therapist

5.1 The specific psychopathology of eating disorders

5.2 Non-specific signs of eating disorders

5.3 Screening for the presence of an eating disorder

5.4 The diagnostic process when an eating disorder is suspected

5.5 Medical diagnostics in patients with an eating disorder

6 Eating disorders and comorbidities

6.1 Epidemiology of comorbidities of eating disorders

6.2 Special aspects of the therapy of eating disorders with comorbidities







The realisation of this book was inspired by many influences. Its foundations were laid by the many decades of experience from working with women and men who are suffering or who have suffered from eating disorders. Essential experience was collected from 1988 to 1999 at the Psychosomatic Clinic Roseneck in Prien am Chiemsee. We are particularly grateful to the team, all physicians, psychologists, nurses, occupational therapists and social workers at the ward for patients with Borderline Personality Disorder at the University of Lübeck, as well as all the patients who have been treated there. It was at this location in 1999 that we started to establish a DBT treatment approach for patients with borderline personality disorder and eating disorders. The concept of the Selfish Brain, which had the greatest influence on formulating our eating disorder therapy, was also established at the University of Lübeck. We would like to mention Professor Fritz Hohagen, the director of the Clinic for Psychiatry and Psychotherapy in Lübeck, whose unconditional trust and support we could always rely upon, Professor Manfred Fichter, a pioneer of behaviour therapy and eating disorder therapy in Germany, Professor Achim Peters, Director of the Clinical Research Group “Selfish Brain”, whose research has led to a new understanding of the relationship between metabolism and emotions, Professor Martin Bohus, who established DBT in Germany, and Professor Christopher Fairburn, a developer of cognitive-behavioural therapy for eating disorders, who tirelessly worked on the development of cognitive therapy and on the scientific rationale behind eating disorder therapy. We would also like to thank the Christina Barz Foundation for their financial support during the creation and testing of this manual. Important people in our group who have contributed to this book include Dr. Oliver Korn, Dr. Kristin Heinecke, Johanna Zabell, Dr. Eva Fassbinder, Dr. Niclas Wedemeyer, Dr. Sebastian Rudolph, Dr. Matthias Anlauf, Mirco Penshorn, Stephanie Friedrich, Dr. Alexia Friedrich, Katherina Burde, Nicole Bach, Stephanie Koglin, Sven Krueger and Doris Gressing, Silke Berg and the entire health care team. Their commitment and perseverance allowed us to implement and test the concept of this therapy in a hospital environment. Dr. Ruprecht Poensgen, the managing director of Kohlhammer Publishing encouraged and supported us to create an English language version of our book. Dr. Julian P. Keogh from PharmACAD Services translated the manuscript. Finally, Alice Buxton, a Psychotherapist and native speaker of both English and German edited the text.





Since ancient times it has been known that mental disorders and abnormal eating patterns are closely linked, as is the case with loss of appetite and impaired mood (melancholy). Anorexia nervosa was mentioned in the 19th Century as the first specifically described eating disorder (Gull 1997; Lasegue 1997), whereas Bulimia nervosa (Russell 1979) and binge-eating disorder (Spitzer 1991) were not described until the end of the 20th century. Specific forms of treatment for eating disorders were first introduced and developed in the last decades of the 20th century.

The best evaluated manual-based, cognitive-behavioural therapeutic approach for the treatment of eating disorders was developed by Chris Fairburn, and is referred to as Cognitive-Behavioural Therapy - Expanded (CBT-E). This treatment method employs a psychological paradigm which focuses on the phenomenon that restrictive eating behaviours in particular are able to compensate for disturbed self-esteem (Fairburn, 2008). CBT-E successfully reduces symptoms, irrespective of the severity of the disease. With a short duration of illness, absence of comorbidity and favourable psychosocial circumstances it can restore even global psychosocial functioning and quality of life. So why develop more behavioural methods? For one thing, remission rates achieved with CBT-E (up to 45 %) have significant room for improvement. Significant limitations arise with the treatment of eating disorders when they are embedded within complex emotion regulation difficulties.

This manual therefore sets a different tone. Scientific data has shown that a disturbance of emotion regulation is a significant cause of psychopathology (Kring and Sloan, 2010) and that it is also an important aspect of eating disorders. In this manual, we therefore rely on the basic assumption that inadequate skills in emotion regulation represent the major sustaining factor for the disorder. This approach is supported by the fact that training of these skills has already proven effective in patients with borderline personality disorder and comorbidity (Chen et al. 2008; Cooper et al. 2007; Telch et al. 2001).

We consider this manual to be within the framework of the psychotherapy development conceptualised as “third wave of behavioural therapy”. Methods within this development abstain from an abstract disputation of thought content from so-called dysfunctional cognitions (for example, the thought “I’m too fat” in a patient with anorexia nervosa). Instead, these new methods deal with the skills that are lacking in certain patient groups in the interpersonal, emotional, and metacognitive domains. In this context, psychotherapy is dedicated more to procedural and emotional learning processes. Another common feature is that themes such as acceptance, mindfulness, dialectics, values, spirituality, fusion-defusion, schemata, relations, but also metacognition and other improvements in cognitive psychology receive attention. All methods within this development adhere to a learning theory framework (Hayes 2004).

The manual is based on the 28 years of experience that the two authors have had in the treatment of eating disorder patients at the Max Planck Institute of Psychiatry, at the Roseneck Clinic in Prien am Chiemsee and in our special ward at Lübeck for patients with eating disorders and personality disorder. Ideas for this manual and psychotherapeutic techniques were incorporated over this time from a variety of sources by attending workshops, reading books and conducting interviews before they were adapted for the treatment of patients with eating disorders. Particularly worthy of mention are individuals such as Frederic Kanfer (Kanfer et al. 1965), Karl-Martin Pirke (Pirke et al. 1986), Manfred Fichter (Fichter, 1989), Marsha Linehan (Linehan, 1993), Martin Bohus (Bohus and Wolf 2009), Matthew McKay (McKay et al. 2007), Steven Hayes (Hayes et al. 1999), James McCullough (McCullough 2001), Adrian Wells (Wells, 2009), John Williams (Segal et al. 2002), Jon Kabat-Zinn (Kabat-Zinn, 2008), Christopher Fairburn (Fairburn, 2008), Achim Peters (Peters et al. 2004), David Barlow (Barlow et al. 2011) as well as the meditation masters the Venerable Ayya Khema (Khema, 1988) and the Venerable Nyanabodhi. An important philosophical source was a book written by Peter Sloterdijk, namely “You must change your life” (Sloterdijk, 2010).

This manual describes a therapeutic option for patients with eating disorders (anorexia nervosa, AN, bulimia nervosa, BN, binge eating disorder, BED, and eating disorder not otherwise specified (EDNOS), especially when the comorbidity of a borderline personality disorder or other mental disorders are present.

Valerija Sipos and Ulrich Schweiger

Handling of the manual




The manual should be handed out to the patient either in parts or in full so that he or she is then able to work through it in full. It represents the common basis both for the patient and the therapist. The manual can either be systematically worked through from the start or an individual strategy may be chosen based on the specific problem of the patient. Such a focus is typically required when the manual is used in combination with a hospitalisation where time is restricted. The manual can be used as a component of an intensive inpatient or outpatient therapy. In this context it can usefully be integrated into group therapies, individual therapies, therapeutically accompanied mealtimes, sports therapies, mindfulness exercises, social skills building exercises and any other complementary activities. It can also be used in an exclusive therapeutic setting or as a self-help manual.

The manual contains information materials and worksheets, but should not be misunderstood as being a psychotherapy cookbook. The focus should remain on the individual psychological paradigm for each patient and the skills that the patient needs in the long term for escaping the vicious cycle of their eating disorder. The therapist should choose the worksheets to work through using this objective as his starting point.




   Part 1

1          Symptoms of the eating disorder module



1.1       Who is this manual for?


The treatment of eating disorders through emotion regulation is aimed at patients who suffer from an eating disorder and other related problems. This module is intended to assist the patient in becoming an expert with his or her own problem. There are many individual variations of eating disorders. In order to plan your treatment accurately, it is important that you know what symptoms are present and what symptoms are not present. If you are unsure whether an eating disorder is a major problem for you, just work through the module and discuss any outstanding issues with your therapist.

For an eating disorder to be present, two criteria must be fulfilled:

1.  The eating behaviour must be altered (e.g., intense fasting, vomiting of food) and

2.  The altered eating behaviour leads to physical endangerment (e.g. underweight, disruptions of mineral metabolism) or psychological impairment (e.g. your whole attention is directed towards thinking about food, depression).

Eating disorders are often associated with problems of emotion regulation. This manual deals with this relationship between emotions and eating behaviour.


1.2       Symptoms of an eating disorder


If you’re wondering whether you are suffering from an eating disorder or not, or if you suffer from an eating disorder and you want to characterise this disease more precisely, then go through the list and consider which symptoms apply to you (worksheet 1).


   Are you underweight or overweight?

The BMI in young women is too low if it less than 18 kg / m2, whereas over 26 kg / m2 it is too high. Health endangering obesity starts at a BMI of 30 kg / m2.

For men, the same relationship exists between BMI and health as it does in women, even if higher limits are given in some tables.

For women and men who engage in power sports, higher BMI limits apply. During the course of a healthy aging process the BMI increases slightly, i.e. a slightly higher BMI is associated with a maximum life expectancy.

For children there is no simple “rule of thumb” for the normal range of weight. It is therefore necessary to use either special tables derived from the internet or paediatric textbooks to determine whether the BMI of a child or adolescent lies within the reference range. These tables use percentiles. Underweight or overweight is considered as the weight below the 3rd or 5th, or above the 95th or 97th percentile.

Waist girth: Waist girth measurements are designed to assess body fat distribution. If a woman’s waist girth exceeds 88 cm and a man’s exceeds 102 cm it is assumed that the volume of abdominal fat (visceral or intra-abdominal fat) is too high. It is important to measure horizontally with a tape measure while standing upright, half-way between the lower ribs and upper edge of the pelvis, and while exhaled and with a relaxed abdominal wall. If you are unsure about this you can let your doctor do the measurement.


   Do you think a lot about food and food related matters?

An important indicator of an eating disorder can be if you constantly think about food or think about your eating behaviour so that it affects your ability to concentrate.


   Do you restrict your calorie intake?

Check which of the following behaviours are typical for you:

   Multiple daily weighings for closely monitoring changes in body weight

   Avoidance of high-calorie, fatty or carbohydrate-containing foods

   Skipping meal components such as desserts or even whole meals

   Chewing and spitting out food

   Precise determination of the calorific content of meals, e.g. by weighing and use of calorie tables

   Avoidance of foods whose calorific content is not clearly identifiable, e.g. where someone else has prepared some soup

   Use of sweeteners, fat substitutes and light products

   Use of appetite suppressants or nicotine for appetite control

    (Self) limitation to one or two meals per day

   Limitation to a certain number of very small meals

   Consumption of large quantities of fluid before meals in order to restrict intake of nutrients

   Restriction of fluid intake in order to make it more difficult to eat (e.g. thirst or dry mucous membranes)

   Shopping for food which you know you do not like to eat in order to control your own eating habits

   Hoarding of food that is looked at but not eaten

   Use of salt, pepper and other spices to make food difficult to eat

   Use of specific thoughts to make the consumption of food that you would otherwise like to eat unappealing. For example, the notion that chocolate is contaminated with mouse droppings or the notion that the chef spat in the soup

   Avoidance of eating publicly in order to avoid distraction while eating

   Avoidance of eating publicly due to shame about one’s eating habits or to prevent others commenting on your eating behaviour

   Use of constricting abdominal belts, confining clothing or muscular tensing in order to create an early feeling of satiation when eating

   Use of tongue piercings or self-injury in the oral cavity to make it more difficult to eat


   Do you try to undertake something once you have eaten?

This refers to all behaviours intended to remove liquids or other energy sources rapidly from the body once they have been consumed.

   Vomiting, either automatically, after stimulation of the throat, or assisted by chemical substances that promote vomiting, such as cough syrup or salt solutions, or vomiting promoted by revolting thoughts

   Consumption of herbal or chemical laxatives

   Consumption of herbal or chemical diuretic agents

   Use of thyroid hormones (to increase the basal metabolic rate)

   Excessive exercise, i.e. exercise that no longer serves an individual’s health or well-being, but which merely burns calories

   Intentional tightening of the muscles (isometric exercises)

   Intentional shivering (by wearing thin clothing) to consume calories

   Intentional sweating to lose fluid (e.g. longer visits to the sauna without adequate fluid replacement)

   Omission of insulin (if you have type 1 diabetes) to excrete sugar in the urine


   Do you eat at unusual times or without a fixed structure?

   Is food consumption distributed throughout the day and without any fixed mealtimes?

   Do you eat sweets instead of meals?

    Do you eat under stress when it is not your mealtimes?

   Do you eat only one meal a day?

   Do you eat more than four meals and snacks per day?

   Do you eat the majority of food at night, after 20:00 and before 06:00 in the morning?

   Do you eat at night when you wake up?


   Do you binge eat?

The term binge eating describes an episode of food consumption during which normal control is lost or not even exercised. If amounts of food are eaten which in terms of calorific consumption far exceed those of a normal meal, this is referred to as objective binge eating. A precise calorie limit has not been defined, but often 1000 kcal is taken as a limit (one exception to this rule comprises meals that are taken on days of intense physical labour or exercise). Food consumption that is unplanned or unwanted, but which do not objectively represent quantities exceeding normal levels of intake can also be subjectively perceived as a binge. With binge eating, foods are typically consumed that would otherwise be “forbidden” or avoided. With a longer lasting eating disorder binge eating episodes are often precisely planned, i.e. foods are purchased specifically for binge eating and plans are made to ensure that nobody interferes with the binge eating. If you are unsure of whether you undertake binge eating or not, make detailed records and discuss them with your psychotherapist or doctor.


   Are there any signs of physical danger?

Eating disorders endanger your physical health and can entail serious and dangerous consequences. Pay particular attention to the following points and let your doctor examine you!



   Disturbances of electrolyte metabolism (most commonly: inadequate levels of potassium and phosphate)

   Disturbances in heart rhythm

   Changes in blood pressure

   Disrupted renal function

   Sex hormone disorders (such as menstrual disorders)

   Disorders of bone metabolism (e.g. fractures occurring at low loads, decreased bone density values upon measurement)


   Does your eating disorder restrict your activities or quality of life?

Eating disorders can lead to severe restrictions of performance at school or work because they draw immensely on concentration and energy resources. In addition, quality of life can also suffer. Preoccupation with food can displace leisure activities or the maintenance of friendships so that there is a danger of falling into isolation and withdrawing from social interactions. With eating disorders where underweight is also present, an increased performance and activity may be present during the early stages of the disease. This situation can conceal the fact that the eating disorder is actually a disease. However, this activated state is at best only temporary.

If several of the above apply and quality of life is affected, you should - if you have not already done so - speak to a specialist who can then carry out a detailed diagnosis.

Common problems associated with eating disorders (comorbidities)

An eating disorder will sometimes be the only psychological problem that a person suffers from. Quite often, however, it can also appear alongside other disorders. Look at the list below to see which situation applies to you.



   You are usually in a bad mood

   You no longer have interest in things that were once important or enjoyable

   You suffer sleep disorders (you do not feel regenerated after sleeping, or you suffer inadequate or even excessive sleep)

   You suffer a lack of drive

   You have an increased perception of pain and other unpleasant bodily sensations

   You have a tendency to ponder and brood, and to worry and ruminate (preoccupation with earlier mistakes)

   You entertain thoughts of not wanting to live any more or even worse, to kill yourself



   You avoid crowds, department stores, subways, car journeys, heights, flying, certain people or certain social situations

   You suffer panic attacks (sudden attacks of intense anxiety with physical signs and a fear of dying or going crazy)

   You preoccupy yourself with concerns and worry (frequent thoughts of the bad things that might happen in the future without any reasonable cause of danger)

   You have compulsions (thoughts that might appear to be exaggerated, but which might compel you to do something to counteract them. For example, the idea: “After touching that doorknob I now have germs on my hands” which then leads you to constantly wash your hands at every opportunity)

    You have intrusive memories (memories of bad situations that have been experienced, and which often force themselves onto you unwillingly)


   Substance abuse

   You drink alcohol in unhealthy quantities

   You take illegal drugs such as cannabis, ecstasy, heroine and/or cocaine

   You smoke tobacco on a daily basis


   Emotional instability (borderline personality disorder)

   You show dangerous impulsive behaviour (e.g. fast driving, dangerous sports, shoplifting, sex with strangers)

   You undergo rapid mood swings

   You undergo rapid changes in your interpersonal relationships

   You have difficulties with being alone

   You inflict self-injury (e.g. by cutting or burning)

   You suffer dissociative states (states such as trance, a lack of memory of situations or conversations, and one’s own person or environment is perceived as alien)


   Timidity and dependence

   You avoid situations in which you can be judged (e.g, when answering questions in school, or when applying for a new, challenging position)

   You rate your own attractiveness and abilities very poorly

   You leave decisions to others



   You require extreme orderliness (everything must be tidy, requirement for symmetry)

   You are not particularly flexible (exceptions to rules cannot be made, the lack of regularity is very disconcerting)

   You attach a high importance to being right

   You are a perfectionist (belief that everything must be done flawlessly, things are better not done than done in an improper way)

If one or more of the above apply, you should - if you have not already done so - speak to a specialist who can then make an accurate diagnosis of your condition.

2          Self-management tools module



2.1       Why is this module important?


This module provides basic information for self-monitoring and shows how you can change your behaviour by undergoing psychotherapy.


2.2       What does a dialectical approach imply?


Dialectical philosophy describes the idea that there are in fact opposing points of view for many of the things in our lives (thesis and antithesis). When these contradicting views are discussed in tandem, something new can be produced which is more than just a mere compromise. The dialectical approach to psychotherapy means that in order to understand disease and processes of change one should not just consider the disadvantages of a disorder, but that one should also consider its benefits. With this approach, eating disorders are not considered to be completely bad for your health and well-being, since they do offer some advantages for you. Fasting, for example, can at least temporarily reduce feelings of fear and shame. Similarly, binging can ameliorate inner stress while vomiting can reduce the fear of gaining weight. The management of the disorder must consider these benefits to the same extent that the disadvantages are taken into account.

Dialectics means

•  Bringing opposites together

•  Looking out for what is present and what is missing

•  “Both-and” thinking instead of “either-or” thinking

•  Observing the current situation and exacting change

•  Being compassionate and caring, but also demanding and confrontational

•  Bringing together rational and emotional needs


2.3       What does changing yourself mean?


The process of overcoming an eating disorder and getting well again is complicated. It requires more than just the desire not to have an eating disorder any more. Paradoxically it can be precisely this desire that may prevent you from ridding yourself of the eating disorder because you then tend to refrain from looking at exactly what the problem is, and to deny the eating disorder and all its related problems. Those who fail to look closely will not know where they are and shall also be incapable of planning an effective strategy.

A more helpful attitude for reflecting on your current situation is: “Yes, I have an eating disorder, and I have good reasons for suffering from this problem. My eating disorder has helped me circumvent aversive feelings so that I suffer less from them. It was a natural reaction to what I have experienced in myself or in my present or past environment. ”

If you feel that you either need to continue with your eating disorder, that your eating disorder brings more benefits than disadvantages for you, or if you feel that any attempt to change would be futile, why not read on anyway? You might still find some information that is both useful and interesting for you.

If you are considering making changes, if the cost-benefit scenario no longer is reasonable and you are predominantly in a state of suffering, or if you are already seriously committed to change, then this manual might be just what you need.

Before you start changing, it is wise to pause and reflect on the process of change, and to talk through and imagine the necessary approaches and processes with your therapist before you start the process of changing your behaviour.

Change is rarely a painless process. If you decide to go on a multi-week expedition to an unknown mountain, the things that might happen to you are predictable for the most part: You will sweat, freeze, experience anxiety and pain, suffer from muscle cramps, and sleep badly, but in the end you will probably feel very proud for what you have done. The whole time you will have to commit your entire physical and mental strength towards coping with the expedition successfully. Overcoming a mental disorder is a similar process: You have to invest a significant portion of your mental energy into the process of change and accept the pain that comes with this change.

Levels of change

Behaviour is controlled at three levels: by internal and external triggers, by habits, and by plans, i.e. behaviour oriented towards values or goals. Approach behaviour represents a behaviour which is sustained by the reward system, for example where a desired result is achieved. Avoidance behaviour is carried out to prevent negative consequences from occurring, such as the experience of pain.

The following examples from everyday life explain these three levels (Table 1):


Table 1: Three levels of behaviour


Table 2: Examples with a bulimic eating disorder

Change can take effect at all three levels. Everyday and unexpected situations (stimuli) must be dealt with in a new way, new habits must be practiced and values and goals need to be reconsidered. It is also important to prepare for the fact that previously avoided emotions can recur with greater than usual vigour when the change process is being undertaken.

It is always important to counteract a problem behaviour at the same hierarchical level: if a particular food, such as chocolate, acts as a trigger for the binge eating episode, this food should not be stored for a certain time in your home, while a conscious effort must be made to purchase other foods in their place. New habits are even more important. If you have been fasting during the day and binge eating only during the evening when you are alone, the new habit must not be compatible with this. You can try eating a predetermined portion of food three times a day, and during the evening doing this together with a friend before leaving home to do something else.

New goals often define your direction. If you are unsure about whether the new goals will suit you, you can first experiment for a week by trying to imagine that you have committed yourself to the new goal and adapting your behaviour accordingly.

The altered situation resulting from the avoidance or addition of elements is referred to as stimulus control. With a bulimic eating disorder it can be helpful for a certain time to eat in company and to refrain from purchasing foods that had previously been important components of binge eating episodes.

The change in behaviour patterns requires old habits to be cast aside and newer (healthier) habits to be adopted.

The change in perception habits can be achieved both by exploring new situations, and by consciously approaching situations “as if they are experienced for the first time” (beginner’s mind). As an example, people with social anxieties and eating disorders often devote their attention to their own appearance when they are in company, or they only pay attention to slim young women or men, and compare themselves with them. The next time you are at a party use the strategy of “Beginner’s Mind”. Imagine being unfamiliar with everybody at the party and examine all guests in exactly the same way. In such a situation it would then be important to observe and describe everyone without rating them as good, bad, beautiful, ugly, I like them or I do not like them. You will then return home with an entirely new perception experience.

During the change process be aware of the differences between “planning”, “brooding” and “worrying”. Planning is oriented towards the skills and behavioural options that you have, and the consequences which might arise from your behaviour and with which probability. During planning, this information is weighed up and a decision is made. Brooding or rumination on the other hand tries to evaluate the past with an emphasis on not repeating past mistakes. This does not involve a goal-oriented problem solving strategy. Worrying orients itself towards the prevention of future disasters. Here you become preoccupied with possible adverse circumstances that do not currently exist, but which could occur if conditions conspire to allow this. Neither brooding nor worrying allow a reasonable view of what the real possibilities of problem solving are in a situation where problem solving is required. Quite the contrary: your thoughts always tend to revolve around the same things so that the process of problem solving is impaired.


2.4       Values and goals


Values are concepts and issues that are important for a person, and to which a person wants to align his or her life. Disorders including eating disorders often cause values to fall by the wayside. Values tend to be formulated more abstractly. Examples include education, professionalism, partnerships, family, music, nature, sports, health, justice, nonviolence, spirituality. Values are never fully realisable, but they do provide direction and orientation. An appropriate analogy would be one or more lighthouses helping a ship to orient itself without ever being reached. Values have the same function in life. They orient behaviour in a particular direction. Goals are concrete steps taken towards realising a value. Appearing on time in the morning at school with all your homework done, for example, would be a goal that would suit the value of education. Meeting a man or a woman in order to get to know them better would be a goal that suits the value of partnership. It makes sense to construct goals that are as close as possible to the present and current reality, which are within ones own capabilities and which are as concrete and feasible as possible. If the goal is a skill you do not possess, goals that focus on learning would be appropriate, such as the attendance of dance lessons if you would like to be a skilful dancer. Life remains balanced if several value areas are considered and suitable goals are pursued to fulfil them. As one example, adequate time can be devoted each week towards several goals, including one’s profession, education, partnership, sports and music. The exclusive pursuit of one value, such as the exclusive focus on work, leads to a one-sided way of life. The worksheet below will help you (re)discover your own values.

The following worksheet should be completed several times during the course of your therapy. The beginning contains an initial orientation, in which you should state where you want your life to go and how you are handicapped by the eating disorder. The worksheet helps you to distance yourself from an exclusive pursuit of short-term solutions. It might open your eyes to the direction in which you want to develop your life in the long term. This should result in the planning of steps to be taken towards fulfilling a more meaningful life.

Worksheet 2 - Values

Area of lifeImportance (1)Achievement of goals (2) How do I live this value?Notes Where am I? Where do I want to go?


Worksheet 3 - Goals



2.5       Learning to plan


Effective planning of one’s own behaviour requires awareness of one’s own needs, values and goals. It also requires that your current situation be acknowledged for what it is, as well as mindfulness. This means that your starting point should be what you care about, what you need, where you are in your life, and what your situation actually is, and that you should carefully observe and inform yourself about your abilities and limitations as well as your opportunities and risks.

In an actual situation when you are planning your behaviour, ask yourself the following questions:

•  What is important to me?

•  What do I need?

•  What are my skills?

•  What obstacles exist?

•  What options do I have for action?

•  What are the opportunities and risks of taking action?

You should go through these questions over and over again whenever you make new plans or revise old ones.

Questions for which no or only vague answers exist are not useful for planning and do not need to be answered:

•  Why is it me who is in this situation?

•  What will happen if some kind of disaster should occur?

It can often help to do an imagery exercise to assess exactly what you want to achieve, and to go over each and every step that you need to take in your mind. If you are unsure of what you can do or what you want to do, you can experiment (for example, do an internship if you are unsure how much you would like to follow a particular career).


2.6       Learn how to deal with dialectical dilemmas


When you consider or plan actions you will often be confronted with situations where two very different alternatives need to be weighed up and that it will be very hard for you to decide between them.

Consider the following examples:

Ms. Brown loves order and precision. Everything has to be tidy. The cupboards are organised the way they would be in a department store. Even in the fridge everything is arranged in a regimented order. Meals are carefully planned. Ms. Brown only buys what she writes down on her shopping list. Each ingredient is weighed accurately and the number of calories is read off and entered into a table.

Ms. Green on the other hand lives in complete chaos. Nothing in her apartment is tidy, and it looks almost as if a bomb had exploded inside it. In her refrigerator fresh food is placed alongside forgotten food that has long gone off. When she goes to the supermarket she always buys whatever takes her fancy. She cooks according to how she feels and does not care about what she eats.

Maybe you find yourself in a situation where you can relate with one of these two women, and maybe you think that this is exactly how your life is. Neither of the described behaviours is “correct”, but both examples include behaviours that can be very useful and helpful for an individual. Think about what walking the middle path would be like and how it might work out for you!

The following dilemmas are common:









Unresolved dilemmas can contribute to overall unhappiness, rapidly changing emotions and in consequence lead to eating disorders. However, the resolution of a dilemma is rarely just a compromise. Often completely new solutions are required and the behaviours used in this situation must be differentiated.

Consider again the examples of Ms. Brown and Ms. Green:

Ms. Brown needs to be more flexible. It is important for spontaneous decisions to be allowed for, e.g. when she sees interesting food while in the supermarket. She can develop confidence in good habits and no longer need to weigh food, read off the calorie content or log figures. She can experience that her desire for stability can still be fulfilled without the need for constant monitoring.

Ms. Green needs some planning in her life: for her it would make sense to learn to keep an account book and write shopping lists. She can set a time once a week when she can clean up and throw away any food which has gone off. She could attend a course at the community college on healthy eating and cooking and then orient her eating habits towards the principles of good health rather than as a reaction to a particular advertisement in the supermarket. Ms. Green will then find out that her desire for spontaneity can still be fulfilled even when she sticks to these basic protocols.

These examples illustrate clearly that Ms. Brown is excessively compulsive and Ms. Green is excessively impulsive. The important thing is not for Ms. Brown to allow some chaos and Ms. Green to allow some order (which would be a compromise) in their lives. The important point is that both need to acquire new skills (which according to dialectics represents a synthesis) to achieve their personal goals in a much more reasonable and efficient manner.


2.7       Learning Theory


If you want to overcome an eating disorder, it is important to know the basic strategies you need to employ to bring about change. Learning theory outlines the strategies and principles that can be used to express desired behaviour more frequently and undesirable behaviours less frequently (in one’s self and in others).