The document summarizes a webinar on creating innovative and effective treatment plans for binge eating disorder that move beyond traditional weight-focused and restrictive dieting approaches. The webinar discusses using Internal Family Systems therapy, experiential therapy, and exposure and response prevention therapy to treat binge eating disorder. It also covers conceptualizing binge eating disorder cases, identifying functions and triggers of binges, and assessing different types of binges.

1. Creating an Innovative and Effective Treatment
Plan for Binge Eating Disorder; Moving Beyond
Traditional Approaches with IFS, Experiential,
and Exposure & Response Prevention Therapies
Castlewood Treatment Center Webinar
February 20, 2013
Katie Thompson, MS, LPC, NCC
Castlewood Treatment Center for Eating Disorders
www.castlewoodtc.com
katie.thompson@castlewoodtc.com

2. FOOD AS PROTECTION?
“As long as my attention was consumed by what I ate, what size
clothes I wore, how much cellulite I had on the backs of my legs, and
what my life would be like when I finally lost the weight, I could not
be deeply hurt by another person. My obsession with weight was
more dramatic and certainly more immediate than anything that
happened between me and a friend or lover. When I did feel rejected
by someone, I reasoned that she or he was rejecting my body, not
me, and that when I got thin, things would be different…the
wonderful thing about food is that it doesn’t leave, talk back, or have
a mind of its own. The difficult thing about people is that they do.”
~Geneen Roth

3. LET’S BREAK IT DOWN
• The reality of Binge Eating Disorder
• Identify components of the treatment process and
conceptualizing a BED case.
• The Binge in detail: functions, triggers,
interventions, Anatomy of a Binge and Types
• Identify traditional & necessary treatment
• Identify innovative & crucial treatment
• Miscellaneous concepts & approaches
• Questions, questions, questions, discussion!

4. THE SIZE AND COST OF BINGES:
•Typical: Between 1,000-2,000 calories consumed.
•25% of Binges included consumption of > 2,000 calories
•Subjective Binges: average or small amounts of food
consumed in a binge; identified as a binge due to the
sense of the loss of control.
•Objective Binges: truly large amounts of food
consumed. Some binges can be 15,000-20,000 calories

5. THE SIZE AND COST OF BINGES:
•In 2009 a study reported the average, cost for binge
food was around $30.5 a week, which adds up to almost
$1,600 a year.
• Some participants reported spending as much as
$3,500 on binge food a year.
•Totals including compensatory items used in the ED
ranged from roughly $360 to almost $8,000 annually.
•By all accounts, this is grossly under-reported. Some
clients report accruing $25,000 of debt in 1-3 years on
binge food and other binge purchases.

6. Necessary Components for Treatment
• Gather a Thorough History and Assess Client
a. Physical, Risk, Dx, Comorbity, ED bx
b. Hx of ED, family hx, Cognitions/Beliefs, TIBs
c. Psychosexual, trauma hx, treatment hx
d. Motivation, attachment, support system
• Establish Safety, Collaboration and Rapport
• Integrate History/Data with Theory to
Conceptualize Case
a. Transdiagnostic Approach
b. Collaboration and Supervision

7. Necessary Components for Treatment
• Provide Psycho-Ed and Anticipatory Guidance
• Symptom Containment and Introduce Relapse
Prevention
• Functions of the Eating Disorder & other Bx
• Correlating how Food/Body became objects
• Identifying unmet needs & addressing
• IDing relationship between Cognitions,
Emotions, Behaviors and Sensations

8. Necessary Components for Treatment
• IDing & addressing unresolved trauma, beliefs,
unfinished business
• Seeing the ED as a protector, healing Exiled
parts protected by ED & healing Protectors.
• Identifying & working with Legacy Burdens
• Work with support systems
• Behavioral Intervention for rituals/behaviors
• Body Image/Affect/Cognitions/Sensations

9. Necessary Components for Treatment
• Revising Relapse Prevention; building
interventions and adaptive coping mechanisms
• Addressing Sexuality & gender issues
• Developing Earned Secure Attachment
• Creating Balanced Living with life skills &
autonomy
• Integrating recovery into life & adjusting
• Building relationships with others

10. FUNCTION OF THE BINGE:
• Survival Strategy • Rebellion
• Provides comfort • Coping mechanism
• Inability to express internal • Substitute for
distress to others. relationship/intimacy
• Call for Help • An OCD ritual
• Fear of responsibility and • Covers horrific memories
growing up • Manifestation of a parent’s
• Manifestation of unresolved unfinished business
trauma and deprivation • A need to care for someone and
• Having something that is one’s escape at the same time
own, not controlled by others. • A way to be out of control
• Numbing privately
• Substitute for • Relief for depression & distress
love/attachment/affection • Keeps others away

11. Function of the Binge: Substitute for Love
“In that moment of spectacle my Will will stand
paralyzed. In an instant I’ll be drawn into the
reality of how empty my heart is, drawn instantly
into a desperate part who believes no person is
willing to fill my heart, the heart that swallows
everything as I had just swallowed the meat. The
meat eating is a metaphor for how vicious I feel
inside. I’m desperate. I need nourishment. My
binge part has ripped through mountains of food,
searching for nourishment, searching for
satiation, frantic for love.”

12. Function of the Binge: Unfinished
Business/Coping Mechanism
“The messages such as ‘you are bad’ respected no boundaries.
They enveloped me and I felt abused and exhausted by them.
So, I developed a mechanism to protect myself. I asked myself
to believe that my self-loathing could live in food instead of
inside of me; eventually the food became my self-hate. By
creating this scenario, I could evade my inherent lacking by
avoiding a vessel that carried hurtful messages. Ironically, I
had decided to evade something essential to my survival so
my plan backfired when I started to crave nutrition. I began
craving food and eventually started bingeing, which fueled my
hatred for the food; bingeing highlighted how unsafe food is.
Bingeing meant that eating will surely possess me with self-
hate; eating is something to be feared and avoided.”

13. Function of the Binge: Manifestations
of Unresolved Deprivation
“The physical deprivation/psychological deprivation binge
happens for me under various circumstances. I can be
especially drawn to a binge if I have successfully eaten
according to my eating disorder’s strict orthorexic rules
for a number of days. Forbidden foods become more
alluring and I feel ashamed that I want them. My eating
disorder is sure that my body doesn’t need them. There
have been few times in the past few years that I’ve
attempted to eat a small amount of a forbidden food. I
tell myself that one to three bites are okay because they
illustrate to other people that I don’t have a problem
with food, that I don’t have an eating disorder…

14. Function of the Binge: Relieve Stress
“Typically, before I know it I’m eating much more
forbidden food than I had intended, I berate myself
for doing so and I realize that I’m going to have to get
it out. This happens commonly at restaurants.
Sometimes I’ll eat more than one piece of bread
from the bread basket or I will eat more than 1-3
bites of a dessert, which means that I’ve broken my
rule. Those extra bites usually happen not because I
am physically deprived but because I am frustrated
by having to follow such rigid rules, tension builds
and I snap.”

15. Function of the Binge: To Keep Others Away
“When stress is added to [the] pot, bingeing was occurring
because on top of my physical deprivation and strict rule
following, I had no emotional regulator. Schoolwork and
studying were enormous triggers for me. Anticipating
social interaction was a trigger as well. I worried about
being awkward and the bingeing and purging process
would sooth the emotions I could not regulate and would
eliminate my incessant ‘what-if-ing’ about the future
social situation. The bingeing and purging could also give
me an excuse to skip the social situation all together. ‘I
feel sick. I feel tired. Look at how disgusting my face is
now that I’ve binged and purged? My stomach feels
upset and my body feels bloated.’”

16. Function of the Binge: To Escape
Responsibility Real or Imagined
“I internalize interpersonal conflict that isn’t actually
happening because when I was young and wondered
if it was happening, I didn’t have a viable adult to ask
because my role in the family required that I take
self-responsibility and also feel responsible for other
people’s emotions. I wonder what I have done wrong
when another person is not happy. So, unhappy
people can trigger me to binge if I am not
successfully able to gain reassurance that I did not
cause the trouble.”

17. Function of the Binge: To Numb
“My perfectionism and self-criticism are always high, so I was
constantly finding fault within myself; this necessitated the
bingeing. I couldn’t handle how hard I was on myself…What the
fuck was wrong with me I would think? I couldn’t handle the
thoughts, and remember, my body was already physically
deprived. I didn’t have a chance. Bingeing worked to sooth these
feelings and eliminate the cycling thoughts. My self-hate and my
anxiety work to ensure that all rules be followed, otherwise they
say that I am a worthless piece of shit. So, when I break the rules
that are impossible not to break, I don’t want to sit around
feeling like a worthless piece of shit, and then I would feel
shame for not accepting my reality as a worthless piece of shit
with grace, so my retribution was to restrict or I would eliminate
all thoughts by bingeing and purging. The bingeing and purging
silenced everything.”

18. Function of the Binge:
“Relief, Numbing, Escape, Satisfaction, Nurturing and
Indulging…all in secret so no one has to know that I
have needs or that I have any issues at all. I am fine. I
am happy. I am need-free. Please love me. I promise I
won’t be a burden. I’ll do my very best. Please love
me.”

19. Illustration of The Binge & Purge

20. Illustration of The Binge & Purge
It commences in the morning with a simple thought
“
that just comes forward in my mind. ‘What do I want
to binge on today?’ Bam, it is settled. The entire
day’s agenda is cemented around the binge and
purge…I want the night to be intimate with my
eating disorder and my punishment…bingeing and
purging is a violent act for me, a deliberate self-
harming act. It is not about calories or weight; it is
about beating up on me…hurt and self-
loathing…hatred…I need to be punished…I must be
punished…obsession, secrecy, shame, guilt, sadness,
self hatred, emptiness, self-loathing, anger, climax,
release, punishment, clean.”

21. Function of the Binge: Interventions
• Create a collage depicting the following: 1) What every
child needs, 2) What you received, and 3) What needs
your eating disorder meets.
• Write about how your eating disorder serves as a
“wedge” between you and others.
• Write out What you get out of the ED and Why it
“works” for you.
• Identify the unmet needs related to the “what” and
“why” of the ED.
• Create urge cards addressing the function of the ED.
Create Adaptive Responses to address unmet needs
related to the urges. Ex: Escape related to Purging.

22. TYPICAL TRIGGERS:
• Fantasizing about forbidden • Restriction, delayed eating
foods or food in general • Deficit of coping skills
• Settings with copious amounts • Anxiety and tension
of food or seeing food • Cravings
• Worries/stress • Eating
• Feeling overwhelmed • Breaking ED rules
• Physical pain, fatigue • Interpersonal conflict
• Alcohol consumption or being • Distorted thinking patterns
disinhibited
• Desire for pleasure • Boredom
• Feeling judged, blamed, • Opportunity (privacy)
rejected, etc. • Feeling like a failure
• Intense or adverse emotions • Trauma Intrusions
• Desire to rebel • Mood instability

23. Mentalizing the Binge
• Identify Sensations, Thoughts and Feelings
leading up to a binge (or specific behavior).
• Have clients connect internally, make mental
notes of the S, T & F.
• Take Clients through a guided imagery journey
into earliest/most prevalent memories that
hold the same S, T & F as the binge holds.
• Way of IDing what binge behaviors are
connected to.

24. Triggers → Beliefs, Emotions & Sensations

25. OVEREVALUATION OF SHAPE &
ACHIEVEMENT

26. TYPES OF BINGES:
1. Stress Binge
2. Hunger Binge
3. Deprivation Binge
4. Opportunity Binge
5. Habit Binge
6. Pleasure Binge
7. Vengeful Binge

27. CYCLICAL ANATOMY OF A BINGE:
Phase 1: Tension Build-Up
• Restriction, delayed eating, deprivation
• Physiological distress
• Adverse/intense emotions
• Conflict
• Thought Distortions, Fantasizing about the Binge,
Planning Binge

28. CYCLICAL ANATOMY OF A BINGE:
Phase 2: Acting Out
• Engaging in the binge
• Dissociation, numbing, distraction
• May include purging or other compensatory
behaviors

29. CYCLICAL ANATOMY OF A BINGE:
Phase 3: Aftermath
• Exhaustion, physical and emotional; lethargic, fatigue
• Binge “Hangover”: headache, nausea, diarrhea,
discomfort
• Sleeping, dissociation, avoidance, disconnection
• Resolve for Change, seeking help, Beginning of Thought
Distortion

30. OTHER WAYS OF BINGEING:
• Alcohol/Drugs
• Sexual Acting Out
• Shopping and Purchases
• Gambling
• Work and productivity
• On a person or a relationship
• On a specific activity: a show, book, etc
• Exercise

31. Assessing the Binge: Interventions
• Write a comprehensive list of the types of binges
you engage(d) in. What are the patterns,
triggers, & functions of each?
• List the Triggers for bingeing. Create interventions
for each.
• List all of the WAYS you binge. What is the
purpose of each of these?
• Map out the Cycles of your Binges. What are the
patterns? Use these to apply to Relapse
Prevention Plan.

32. TRADITIONAL APPROACHES
• Weight-loss & Diet Approaches
• Restrictive Dieting (popular in hospitals, etc.)
• Surgical interventions
• Goals: Weight reduction through restrained caloric intake,
sometimes paired with exercise and anorectic medication
(Romano 1995)
• Obesity Treatment Models: Focus on treating the “excess
weight,” before dealing with psychological issues.
• Some Obesity Experts also believe that BED is not a public
health concern, therefore not requiring the focus that “the
obesity epidemic warrants” due to the consequences-
hypertension, stroke and heart attack-that obesity pose.
• Self-Help Groups
• 12 Step Models (OA)

33. TRADITIONAL TREATMENT APPROACHES
• Traditional Treatment Approaches are
necessary, crucial, but not sufficient. They
create the opportunity for recipients to
address behavioral and cognitive change
necessary for long-term recovery.
• Cognitive Behavioral Therapy (CBT)
• Behavioral Modification (More effective with
CO)
• Traditional Dialectical Behavioral Therapy
(DBT)

34. INNOVATIVE TREATMENT APPROACH
• DBT for Binge Eating and Bulimia (Safer, Telch
& Chen, 2009)
• Focuses on Individual and Group
Psychotherapy in a 20 week format
• Utilizes 3 of 4 of Linehan’s skills training
modules: Mindfulness, Emotion Regulation,
Distress Tolerance
• Cohesive revision of the traditional Linehan
DBT for Borderline Personality Disorder

36. Diary Card
Diary Card This week I filled out this side of the diary Urge to leave treatment/quit therapy (0 – 7)
For week beginning: card
Mon Tue Wed Thur Fri Sat Sun (circle one) ____ each day Before therapy session ____
____ 4-6 times After therapy session ____
On Date ____/____/____ ____ once
____ 2-3 times
Day Urge Urge to Urge to Urge Other Submit Submit Submit Submit Submit Disconnected AIBs Food Preoccupied A S F S P H Rate
to Restrict Exercise to Self Urges: to To To Self to to other Eating Did you Cravings? with food? N A E H R A How
Purge or Harm Purge Restrict Harm Exercise Urges How many set G D A A I P Much
Binge Body or times? yourself E N R M D P You
(ID) Check, Binge (how) up? R E or E E I Used
avoidance, (ID) S A N Skills
Isolation. S N E (0 – 7)
X S
I S
E
T
Y
MON
TUE
WED
THUR
FRI
SAT
SUN
*Please rate from 0 to 7 the highest rating for the day (0 = did not experience the urge/thought/feeling, to 7 = experienced the urge/thought/feeling intensely)
@USED SKILL:
0 = Not thought about or used 4 = Tried, could use them, but they did not help
1 = Thought about, not used, didn’t want to 5 = Tried, could use them, helped
2 = Thought about, not used, wanted to 6 = Used skills without trying, didn’t help
3 = Tried but couldn’t used them 7 = Used skills without trying, helped

37. Skills Used Today
Skill Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Journaling
Affirmations
Artwork/Puzzle
Containment
List/Box/Imagery
Checking In
Asking for Help
Self-care
Binge/Bx Chain
Analysis
Processed in
Group/Sessions
Self Care
Spending time with
Peers
Disclosing about
Behaviors
ADL’s
Grounding
Safe Place
Leisure Time
Recovery
Statements
Ban Book

39. Daily Check-In
Each day I commit to voicing my urges in an appropriate and healthy way, I commit to following my
meal plan and to abstaining from behaviors. Should I struggle, l commit to struggling in a recovery-
focused way with honesty. This means seeking support before I become overwhelmed and use
behaviors.
_____ Abstained from Purging
_____ Abstained from Restricting
_____ Took all medications as prescribed
_____ Followed Fluid Protocol
_____ Used ACRs for Practice
_____ Used ACRs when Needed
_____ Used Voice at Meal when Struggling
_____ Formal Check ins with Staff daily
_____ Completed All Exposures and Therapeutic Assignments
_____ Practiced Using Internal and External Resources
_____ Engaged in Self-Care
_____ Journaled when Overwhelmed
_____ Socialized with Peers
_____ Asked for Support when necessary
_____ Use Resources when SH Urges are Present
Challenges from the Day:
Successes from the Day:
Goals for Tomorrow:
Affirmation for Today:

40. Distress Tolerance Scale (by Simons and Gaher)
Directions: Think of times that you feel distressed or upset. Select the item
from the menu that best describes your beliefs about feeling distressed or upset.
1. Strongly agree
2. Mildly agree
3. Agree and disagree equally
4. Mildly disagree
5. Strongly disagree
1. Feeling distressed or upset is unbearable to me.
2. When I feel distressed or upset, all I can think about is how bad I feel.
3. I can’t handle feeling distressed or upset.
4. My feelings of distress are so intense that they completely take over.
5. There’s nothing worse than feeling distressed or upset.
6. I can tolerate being distressed or upset as well as most people.
7. My feelings of distress or being upset are not acceptable.
8. I’ll do anything to avoid feeling distressed or upset.
9. Other people seem to be able to tolerate feeling distressed or upset better than I can.
10. Being distressed or upset is always a major ordeal for me.
11. I am ashamed of myself when I feel distressed or upset.
12. My feelings of distress or being upset scare me.
13. I’ll do anything to stop feeling distressed or upset.
14. When I feel distressed or upset, I must do something about it immediately.
15. When I feel distressed or upset, I cannot help but concentrate on how bad the distress
actually feels.

41. DTS Scoring Information:
Scoring: Item 6 is reverse scored.
Subscale scores are the mean of the items.
The higher-order DTS is formed from the mean of the four subscales.
The four scales are:
Tolerance: questions 1, 3, 5
Absorption: questions 2, 4, 15
Appraisal: questions 6, 7, 9, 10, 11, 12
Regulation: questions 8, 13, 14
The higher the score, the lower the distress tolerance abilities are.
*There is no scale for scoring; authors state it is meant to be used as a
continuous measure.

42. DBT for BED Interventions
• Identify current & past TIBs, identify function of each,
explore & practice adaptive interventions to address unmet
needs.
• Keep daily Diary Card and monitor relationship between
urges/behaviors/skills used/events
• Use daily check-in sheet to facilitate mindfulness & allow
monitoring of T,F,B,S
• Create a daily recovery plan (bookends) and monitor
outcome of using plan
• Complete a Behavioral Chain Analysis, Share & apply to
relapse prevention
• Create Urge cards, match type of interventions to unmet
need/urge and intensity of intervention to intensity of urge

43. INNOVATIVE TREATMENT APPROACHES:
INTERNAL FAMILY SYSTEMS (IFS)
• Identify SELF as made up of “parts” aka: beliefs and
feelings that define aspects of a person.
• The ED is a “part” of a person, often multiple parts,
with the function of protecting the individual.
• Parts serve a function(s) to either manage, alleviate
distress, or hold/protect secrets/beliefs/feelings
distressing to the SELF. (Managers, Firefighters, Exiles)
• Goal: meet & understand parts of self, especially
protector parts like: Restriction, Bingeing, Purging
• Goal: Allow ED parts to reveal function/role and work
towards unburdening them of the role(s) keeping them
in the eating disorder.
• Burdens are comprised of feelings and core beliefs that
solidified from traumas & incidents or events from past

45. INNOVATIVE TREATMENT APPROACHES:
INTERNAL FAMILY SYSTEMS (IFS)
• “Unblending at the Table”
• Containment/Grounding skills utilized before, during and
after meal in which the client identifies which parts are
activated, present and merged throughout interactions
with food.
• Before: Identifying emotions and thoughts present prior to
interacting with food that would facilitate need or desire
for use of ED behaviors during meal or after.
• Inviting Parts to “step back” or create space for individual
to engage with food without undue distress and behaviors.
• During: Continual dialogue internally to manage feelings
and distorted ED beliefs that surface throughout the meal
that influence the decisions a person makes with food.
• After: Dialoguing with thoughts and feelings; AKA Parts
after the meal/snack to create space.

46. Unblending at the Table
1. Explain concept of being “blended” or merged with parts.
2. Explain rationale for creating space for SELF at the table (and in general).
3. Explain value in practicing before meals and at other crucial times.
4. Evaluate what Parts often approach table with the client (guided imagery technique).
5. Teach Steps for Unblending.
Steps for Teaching Unblending
1. Focus inside and identify which emotions/beliefs (AKA Parts) are present at this moment.
2. Invite Parts to allow space for client to connect to food.
3. Teach Client about value of having parts present but unmerged. Teach about “chair,” “bench,” “swing.”
4. Techniques for Unblending (Mike Elkin Handout)
5. Need for Unblending throughout meal.
6. Explaining rationale in dialogue with Parts; reaching agreement for time and space for Parts.
7. Allowing Parts time and space at designated time for journaling dialoguing.
8. Value of bringing Parts feelings and Beliefs into later sessions/groups.
Steps for Unblending Practice for Client
1. Focus inside and identify Parts that are present.
2. Acknowledge and Welcome Parts
3. Ask Parts to take place on designated space for meal/snack time.
4. Utilize Unblending techniques if necessary.
5. Continue Unblending Dialogue throughout meal/snack.
6. Thank Parts after completion of meal/snack. Acknowledge Commitment for later Dialogue.
7. Dialogue at later Time through Journaling.
8. Engage in Resolution via check-ins, sessions or groups.

47. INNOVATIVE TREATMENT APPROACHES:
INTERNAL FAMILY SYSTEMS (IFS)
• Group and Individual session IFS work support the
unblending practices.
• In IFS work, client begins to understand functions of
different acting out behaviors and the exiled parts
these “managers” and “firefighters” protect.
• Work to unburden “Protectors” & “Exiles” and give
these parts new, helpful roles rather than protector
roles that harm the person.
• Exiles unload burdens which reduces need for ED parts
and other protectors.
• Can be connected back to earlier emotional
experiences (see activity)
• Healing work with core experiences/dynamics can
diffuse need for ED behaviors/parts

48. IFS for BED Interventions
• Write a summary of each IFS session.
• Follow through on commitments made to Parts in IFS work,
integrate into daily Recovery Plan/Routine
• Create a “Parts Map” as you come to understand the Parts
of You/SELF and the ED
• Practice “Unblending” & use at/away from table
• Practice Safe Place Imagery & work with Parts
• Engage in daily dialoguing with Parts of SELF
• Identify of list of Unmet Child Needs & actively set
goals/exposures to meet needs & wants.
• Understand your Polarizations; write about rules & beliefs
of each Part of the ED, the feelings & the Goals of each Part
(R, B, P, E, SH, etc).

49. INNOVATIVE TREATMENT APPROACHES:
EXPOSURE AND RESPONSE/RITUAL PREVENTION
• ERP is an offshoot of CBT and is effective at
treating the cognitive, behavioral and often
emotional end of the ED.
• Originally designed to treat OCD, SAD and
GAD; now effective in treating aspects of the
ED.
• Create a hierarchy of feared food items and
food situations each rated based upon the
level of anxiety the stimulus provokes.

50. INNOVATIVE TREATMENT APPROACHES:
EXPOSURE AND RESPONSE/RITUAL PREVENTION
• Exposures are then created from the hierarchy.
• Concept is around exposing individual to feared
stimuli in a challenging but manageable fashion
enough that the anxiety around the stimuli
decreases over time. This anxiety reduces within
the trials of the exposure and between trials.
• Exposures can be experiments, more formalized
and can be recorded to show habituation; aka
improvement interacting with stimuli without
anxiety response.
• Exposures can be imaginal, in person, with actual
food, and with actual environments.

51. INNOVATIVE TREATMENT APPROACHES:
EXPOSURE AND RESPONSE/RITUAL PREVENTION
• Exposures can involve feared food items,
feared situations with food, forbidden foods,
binge foods, trauma foods etc.
• Experiments can be completed with staff
support, with a group, at a meal/snack.
• Goal is to complete 70% of hierarchy.
• Goal is also to be able to interact with food
without engaging in ED behaviors.

52. ANXIETY RATING SCALE
0 1 2 3 4 5 6 7
TRY AS HARD AS POSSIBLE TO RESIST
HAVE TO RESIST
Difficult to resist
Challenging Challenging
“It bothers me” urges.
Anxiety is
CALM bothersome, yet Unsure if able to Extremely hard to
“Don’t want to do “Wish I didn’t
NO ANXIETY manageable. resist ritualizing. resist urges to Panicking
it but know it will have to do it, but Near panic
NO URGES TO ritualize.
be easier than I can do it. Glad
RITUALIZE AT A little bit harder Very hard to Fear of dying.
think.” when it’s over!”
ALL to resist urges but resist urges to Start feeling
can still do it. ritualize. symptoms of
A few urges to Come close to
panic.
ritualize. ritualizing but can
still resist.
Can’t imagine making
A few weeks before Think about ‘faking it through the
EXAMPLE: Dreading going. Don’t know if I can
appointment. Think being sick.’ Trying to appointment. Think
Really don’t want to, make it. Feel some Refuse to go. PANIC
GOING TO about not wanting to make excuses. Go to about leaving in the
but know it will panic symptoms Feeling panicky. Fear of dying if I go.
THE DENTIST
go, but no it, but glad when it’s middle of the
be ok if I go. starting.
worries, really. over. appointment. Strong
relief when I make it.

53. Exposure Exercise: ____________________________________________________
Trial Peak Anxiety Final Anxiety
Date Time Elapsed Time
# Rating Rating
1
2
3
4
5
6
7
8
9
10

54. ERP INSTRUCTIONS
GENERAL INFORMATION
Pick 5-10 exposures from your hierarchy that you want to work on.
Work with your adjunctive or anxiety therapist to identify the current exposures.
When an exposure is crossed off choose another to replace it.
Choose a variety of exposures.
It is very important that you record every exposure and monitor your progress.
CONDUCTING EXPOSURES:
The goal of exposures is to achieve within and between trial habituation.
Within trial habituation is a reduction of your anxiety within each individual trial.
Example: from a 2 to a 1.
Between trial habituation is a reduction in your peek anxiety level between trials.
Example: your first trial, the anxiety went from a 2 to a 1. In the second trial your
anxiety reduces from a peak of 1 to a 0. The reduction in peak anxiety levels from Trial
1 (2) to Trial 2 (1) is between trial habituation.
Conduct at least 6 (preferably more) trials of an exposure at a time before moving on to
another exercise. This helps you to achieve between trial habituation and to move through
your hierarchy more quickly.

55. ERP INSTRUCTIONS
HOW DO I CONDUCT EXPOSURES?
Choose one you have decided to work on and do what it says. Example: Place Peanut
Butter on index finger.
Take note of the time you begin the exposure!
Once you have started the exposure (PB on Finger) rate your peek anxiety on the 0 to 7
scale (0 = no anxiety to 7 = extremely high unmanageable anxiety). Let’s say it was a 4.
Continue conducting the exposure (PB on Finger) till your peak anxiety has come down by
half. Example: from a 4 to a 2.
Note the time that has elapsed while conducting the exposure.
Remember to continue the exposure (PB on Finger) until the anxiety has come down by at
least half. This may take several minutes or longer. If your anxiety has not come down in
30 minutes discontinue the exposure.
If your peak anxiety is a 5 or above, discontinue the exposure and move it to the appropriate
anxiety level on your hierarchy.

56. ERP INSTRUCTIONS
HOW DO I RECORD EXPOSURES?
Use the Exposure Record form located in your homework binder.
Place the name of the exposure at the top.
Follow the guidelines on the sheet. It should look similar to this:
Trial Peak Anxiety Final Anxiety
Date Time Elapsed Time
# Rating Rating
1 1/15/03 4:30 PM 4 7 min. 2
After conducting a trial, wait until your anxiety has returned to 0 before conducting another
trial. This is to avoid any potential accumulation of anxiety.
When reporting exposures, you will say, “touch doorknob, 4 to a 2 in 7 minutes.”
Cross Off Rule: Exposures are crossed off when you have conducted at least 3 trials on two
different days for a minimum of 6 trials in which your peak anxiety rating was 0 and your final
anxiety rating was 0. It is important to remember that even though you have crossed
off an exposure, you are still responsible for conducting that behavior in your daily
life (i.e.Touching PB in Everyday life).

57. BANS
Bans are a very important part of treatment, as they constitute the “response prevention” portion
of exposure & response prevention. They address the compulsive behaviors you carry out to
reduce your anxiety. In order for the exposure exercises to be completely effective you will
need to reduce and eventually eliminate the amount of times you conduct these compulsive
behaviors. The ultimate goal is to reduce these behaviors to 0 as soon as possible! Therefore,
we want you to keep track of the number of times you conduct these behaviors (submits) and
the number of times you wanted to conduct these behaviors but did not (resists). To record
your bans we suggest you get a small hand notebook (like a reporter’s notebook). Keep track of
your bans daily, from the time group ends until the time the next group begins. We suggest
tracking your bans like this:
BAN: Body Checking
SUBMITS RESISTS
// ////
** Remember, it is important to record your bans & reduce them to 0 as soon as possible. **

59. CBT for ED Diary Card
Day of Week:
Date:
Time of Meal Actual Meal: Urges:B/P/R
Binge? Purge? Restrict? Rituals? Thoughts –Feelings – Events?
Day: Plan: Fluids: (0-7)?
BF
AM
L
PM
D
HS

60. ERP Interventions for BED
• Create a hierarchy of Binge Foods, Fear Foods, Forbidden Foods
& Trauma Foods. Rate each on 0-7 or 0-10 anxiety scale. Identify
situations that influence the rating.
• Work with Therapist to set up exposures.
• Complete Exposures, process & use to guide further
exposures/experiments and hierarchy
• Create a list of anxiety provoking body image/movement
situations and work with therapist to create experiments &
exposures.
• Begin moving in body & challenging avoidance or urges.
• Write about all of your rituals with food & your body in detail.
What are fears around change? What is the function of each.
Integrate into hierarchy as needed.
• Write about fears of allowing yourself to taste, enjoy or desire
food. Write about fears of allowing yourself to connect to &
“embody” your body.

61. INNOVATIVE TREATMENT APPROACHES:
EXPERIENTIAL and Miscellaneous THERAPIES
• Encompasses Drama and Expressive Therapies
in which individuals apply cognitions and
feelings into action.
• Art, music, etc.
• Guided Imagery: Examples of Guided Imagery
from Group Sessions
• Improv Therapy
• Attachment Theory as related to the Binge
• Bingeing and Body Movement

62. Parallel Arousal Systems:
Attachment ~ Crittendon
Attachment Sexual
• Pain • Sexual Pain
• Fear • Sexualized Terror
• Anger • Aggression/Submission
• Desire for Comfort • Romanticism
• Comfort • Affection
• Bored • Satisfaction
• Tired • Afterglow
• Sleep • Sleep
• Depression • Numbness

63. Parallel Arousal Systems:
Attachment
Attachment Food
• Pain • Starvation/Stuffing
• Fear • Forbidden/Fear Foods
• Anger • Anger at Food
• Desire for Comfort • Fantasizing about Food
• Comfort • Food as Comfort
• Bored • Satiation
• Tired • Exhaustion after R/B/P
• Sleep • Hangover/Sleeping
• Depression • Numbness

64. Bingeing and The Body
• It is necessary to evaluate client’s relationships with
their bodies.
• Identify the way a client feels in their body before,
during and after the binge behaviors.
• Relationship between the binge and exercise
• Relationship between the binge and exercise
avoidance.
• Challenge thought distortions about bodies and ED
behaviors.
• Create exposures & interventions to help the clients
create balance and develop a healthy relationship with
their bodies.

65. BRIEF BASICS ABOUT BINGE EATING AND THE
LIKE
Proposed DSM-V Definition of Binge Eating
Disorder:
A. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following:
(1) Eating, in a discrete period of time (e.g., within any 2-
hour period), an amount of food that is definitely larger
than most people would eat in a similar period of time
under similar circumstances
(2) A sense of lack of control over eating during the
episode (for example, a feeling that one cannot stop
eating or control what or how much one is eating)

66. BRIEF BASICS ABOUT BINGE EATING AND THE
LIKE
Proposed DSM-V Definition of Binge Eating
Disorder, cont’d:
B. The binge-eating episodes are associated with 3 (or
more) of the following:
(1) Eating much more rapidly than normal
(2) Eating until feeling uncomfortably full
(3) Eating large amounts of food when not
feeling physically hungry
(4) Eating alone because of feeling
embarrassed by how much one is eating
(5) Feeling disgusted with oneself,
depressed, or very guilty after
overeating

67. BRIEF BASICS ABOUT BINGE EATING AND THE
LIKE
Proposed DSM-V Definition of Binge Eating
Disorder, cont’d:
C. Marked distress regarding binge eating is present
D. The binge eating occurs, on average, at least once
a week for 3 months
E. The binge eating is not associated with the
recurrent use of inappropriate compensatory
behavior and does not occur exclusively during
the course of Bulimia Nervosa or Anorexia
Nervosa

68. BRIEF BASICS ABOUT BINGE EATING AND THE
LIKE
Proposed DSM-V Definition of Bulimia Nervosa:
A. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following:
(1) Eating, in a discrete period of time (e.g., within any 2-hour
period), an amount of food that is definitely larger than most
people would eat during a similar period of time under similar
circumstances
(2) A sense of lack of control over eating during the episode
(e.g., a feeling that one cannot stop eating or control what or
how much one is eating)

69. BRIEF BASICS ABOUT BINGE EATING AND THE
LIKE
Proposed DSM-V Definition of Bulimia Nervosa:
B. Recurrent inappropriate compensatory behaviors in order
to prevent weight gain, such as self-induced vomiting; misuse
of laxatives, diuretics, or other medications, fasting; or
excessive exercise.
C. The binge eating and inappropriate compensatory
behaviors both occur, on average, at least once per week for 3
months.
D. Self-evaluation is unduly influenced by body shape and
weight.
E. The disturbance does not occur exclusively during episodes
of Anorexia Nervosa

70. BRIEF BASICS ABOUT BINGE EATING AND THE
LIKE
Revision of DSM-IV Criteria:
B. Recurrent inappropriate compensatory behavior in order to
prevent weight gain, such as self-induced vomiting; misuse of
laxatives, diuretics, enemas, or other medications; fasting; or
excessive exercise.
C. The binge eating and inappropriate compensatory behaviors
both occur, on average, at least twice a week for 3 months.
Purging Type: during the current episode of Bulimia Nervosa, the
person has regularly engaged in self-induced vomiting or the
misuse of laxatives, diuretics, or enemas
Nonpurging Type: during the current episode of Bulimia Nervosa,
the person has used other inappropriate compensatory behaviors,
such as fasting or excessive exercise, but has not regularly engaged
in self-induced vomiting or the misuse of laxatives, diuretics, or
enemas

71. BRIEF BASICS ABOUT BINGE EATING AND
THE LIKE
Compulsive Overeating:
•May Co-exist with BED
•“consuming larger than required amounts at meal times,
eating throughout the day and eating inappropriately in
response to multiple cues. Often, there is little meal
structure. “
•“Behavior is often described as ‘grazing,’ and predictably
underscore the fact that they are not generally responding to
hunger. “
•“Preliminary data on BED seems to highlight the relative
psychological health of compulsive overeaters in comparison
to those exhibiting regular bingeing behavior. “
~Romano & Quinn 1995

72. References
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Albers, S. (2009). Eat Drink and Be Mindful. Oakland: New Harbinger Publications.
Cooper, M., Todd, G., Wells, A. (2009). Treating Bulimia Nervosa and Binge Eating: An Integrated
Metacognitive and Cognitive Therapy Manual. London: Routledge.
Fairburn, C. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: The Guildord Press.
_____. (1995). Overcoming Binge Eating. New York: The Guildford Press.
Nash, J.D. (1999). Binge No More: Your Guide to Overcoming Disordered Eating. Oakland: New
Harbinger Publications.
Roth, G. (1991). When Food Is Love: Exploring the Relationship Between Eating and Intimacy. New York: Plume.
Safer, D.L., Telch, C.F., Chen, E.Y. (2009). Dialectical Behavior Therapy for Binge Eating and Bulimia. New York:
The Guilford Press..
Schwartz, R.C. (1997). Internal Family Systems Therapy. New York: The Guildford Press.
_____. (2001). Introduction to the Internal Family Systems Model. Fort Collins: Trailhead Publications..
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