Binge eating disorder (BED), a chronic condition characterized by eating disorder psychopathology and physical and social disability,represents a significant public health problem. Guided self-help (GSH) treatments for BED appear promising and may be more readilydisseminable to mental health care providers, accessible to patients, and cost-effective than existing, efficacious BED specialty treatments,which are limited in public health utility and impact given their time and expense demands. No existing BED GSH treatment hasincorporated affect regulation models of binge eating, which appears warranted given research linking negative affect and binge eating.This article describes Integrative Response Therapy (IRT), a new group-based guided self-help treatment based on the affect regulationmodel of binge eating, which has shown initial promise in a pilot sample of adults meeting DSM-IV criteria for BED. Fifty-four percentand 67% of participants were abstinent at posttreatment and 3-month follow-up, respectively. There was a significant reduction in thenumber of binge days over the previous 28 days from baseline to posttreatment [14.44 (±7.16) to 3.15 (±5.70); t=7.71, pb .001;d=2.2] and from baseline to follow-up [14.44 (±7.16) to 1.50 (±2.88); t=5.64, pb .001; d=1.7]. All subscales from both the EatingDisorder Examination–Questionnaire and Emotional Eating Scale were significantly lower at posttreatment compared to baseline. Onehundred percent of IRT participants would recommend the program to a friend or family member in need. IRT's longer-term efficacyand acceptability are presently being tested in a NIMH-funded randomized controlled trial.
Prevalence and Consequences of BED
Binge eating disorder (BED), a diagnostic researchcategory in the Diagnostic and Statistical Manual of MentalDisorders (American Psychiatric Association, 1994), is achronic disorder characterized by recurrent episodes ofbinge eating without the requisite compensatory behaviorsseen in bulimia nervosa. BED impacts approximately 2% to5% of the general population (Bruce & Agras, 1992), up to30% of weight control program participants (Spitzer et al.,1992; Spitzer et al., 1993), and up to 49% of thoseundergoing bariatric surgery (de Zwaan et al., 2003;Niego, Kofman, Weiss, and Geliebter, 2007). Findingsfrom clinic, community, and population-based studies notethat BED is associatedwith overweight and obesity (Bruce&Agras; Fairburn, Cooper, Doll, Norman, &O'Conner, 2000;Smith, Marcus, Lewis, Fitzgibbon, & Schreiner, 1998;Spitzer et al., 1992; Striegel-Moore, Wilfley, Pike, Dohm,& Fairburn, 2000) and the prevalence of binge eatingincreases with the BodyMass Index (Telch, Agras, Rossiter,
-7229/11/93-105$1.00/012 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.
1988). Through its association with overweight and obesity,BED includes a greater risk for many serious medicalconditions (Pi-Sunyer, 1993; Pi-Sunyer, 1998). In addition,when compared to overweight persons without BED,overweight persons with BED have increased rates of AxisI and Axis II psychopathology (Marcus et al., 1990; Mitchell& Mussell, 1995; Yanovski, 1993) and increased rates ofinterpersonal and work impairments due to weight andeating concerns (Spitzer et al., 1993).
Existing Treatments for BED
Existing treatments for BED include pharmacologicalapproaches and psychotherapeutic treatments includingcognitive behavioral therapy (CBT), interpersonalpsychotherapy (IPT), dialectical behavior therapy forBED (DBT-BED), behavioral weight loss (BWL), andvarious forms of guided self-help (GSH). While pharmaco-therapy and specialty psychotherapeutic treatments (e.g.,CBT, IPT, DBT-BED) have demonstrated at least moderateefficacy (Vocks et al., 2010), an impetus remains for thedevelopment of new BED treatments and further BEDresearch. First, existing treatments yield a significantnumber of patients who are still symptomatic at posttreat-ment and follow-up (Munsch et al., 2007; Safer, Robinson,Jo, 2010; Wilfley et al., 2002; Wilson, Grio, & Vitousek,2007). Second, specialty treatments are expensive, time-
intensive (often administered in 6 months of weekly 1- to 2-hour therapy sessions), and require expert delivery (e.g.,therapists typically hold at least a master's degree and havereceived advanced training in eating disorders), andtherefore are limited in ease of dissemination and patientaccess. Next, pharmacological treatments, while appearingsuperior to placebo, yield approximately 50% symptomaticindividuals at posttreatment and data on longer-termabstinence rates postmedication cessation are limited(Reas & Grilo, 2008). Last, BWL offers a less-expensivetreatment option than specialty treatments, yet BWLmaynotbe effective in the treatment of BED over the long term(Grilo et al., 2011; Wilson, Wilfley, & Agras, 2010).
BED self-help research has varied in terms of method-ological quality (e.g., sample size, pathology assessment),settings, and intervention implementation details (Wilson,2005). Consequently, strikingly different outcomes havebeen reported. Nonetheless, GSH is short term andgenerally less expensive and more easily disseminablethan the specialty treatments (Vocks et al., 2010). Researchindicates that GSH programs, including CognitiveBehavioral Therapy Guided Self-Help (CBT-gsh), aresuperior to wait-list conditions and may be equivalent tospecialty treatments in reducing binge eating and relatedeating disorder symptoms. Reviews investigating GSHand Pure Self-Help (PSH) for BED and BN agree on theutility of GSH and PSH, and recommend furtherinvestigation of self-help approaches (Perkins, Murphy,Schmidt, & Williams, 2006; Stefano, Bacaltchuk, Blay, &Hay, 2006; Vocks et al.). Perkins et al. (2006) found nosignificant differences between GSH or PSH and otherformal, specialty psychological treatment approaches atposttreatment or follow-up on bingeing or purging, othereating disorder symptoms, level of interpersonal func-tioning, or depression. In addition, while GSH and PSHwere not significantly different than a wait-list conditionat posttreatment on bingeing and purging, they yieldedsignificantly greater improvements at posttreatment onother eating disorder symptoms, psychiatric symptom-atology, and interpersonal functioning. Moreover, nosignificant differenceswere found in dropout rates betweenGSH and formal therapist-delivered psychological thera-pies, or betweenGSHandPSH (Perkins et al.; Stefano et al.,2006; Vocks et al.). A recent trial compared CBT-gsh, IPT,and BWL and found no significant differences among thethree treatments in remission from binge eating, reductionin number of days of binge eating, or no longer meetingDSM-IV criteria for BED at posttreatment and 1-year follow-up (Wilson et al., 2010). While IPT and CBT-gsh were notsignificantly different from one another at 2-year follow-up,both were superior to BWL. Other studies have similarlydocumented GSH's durability of binge eating reductionthrough follow-up (Carter & Fairburn, 1998; Peterson et al.,2001). Perkins et al. (2006) concluded that (a) evidence,
though limited, supports the use of self-help in thetreatment of recurrent binge eating disorders and(b) insufficient evidence supports any particular self-helpapproach (e.g., PSH or GSH) over another, and (c)additional self-help research, including randomized con-trolled studies that apply standardized inclusion criteriaevaluation instruments and self-help materials, are needed.A third review of various guided and unguided self-helptreatments for BED and BN concluded that self-help yieldsmaintained improvements in eating disorder symptoms atfollow-up (between 3 and 18 months posttreatment; Sysko&Walsh, 2008). In addition, limited studies were found thatimplemented variations of GSH in a group therapymodality (Peterson et al., 1998; Peterson et al., 2001;Peterson et al., 2009). Thus, self-help is a promising yetunderstudied approach to the treatment of BED.
Affect Regulation in BED Treatment
There is an extensive literature investigating therelationship between negative affect and binge eating thatrepeatedly cites significant associations between the pres-ence of negative mood and the onset of a binge eatingepisode (Abraham& Beumont, 1982; Agras & Telch, 1998;Polivy & Herman, 1993; Stice & Agras, 1998; Stickney,Miltenberger, & Wolff 1999; Telch & Agras, 1996; Wegner,Smyth, Crosby, Wittrock, Wonderlich, & Mitchell, 2002).For example, negative mood was found to be significantlyhigher at pre-binge compared to nonbinge times amongwomen with BED, and participants attributed their bingeepisodes to mood more frequently than hunger or binge-abstinence violation (Stein et al., 2007). The affectregulation model of binge eating conceptualizes bingeeating as an attempt to alter painful emotional states(Linehan & Chen, 2005; Polivy & Herman, 1993; Waller2003;Wiser &Telch, 1999) and postulates that binge eatingis maintained through negative reinforcement as it pro-vides temporary relief from aversive emotions (Arnow,Kenardy, & Agras, 1995; Smyth et al., 2007; Wiser & Telch).Stein and colleagues, conversely, question the purpose ofbinge eating as relief from negative mood given their dataindicating significant elevations in negative mood at post-binge times. However, one might postulate that bingeeating's temporary relief from pre-binge negative moodoccurs only during the act of bingeing, and subsequentlynegative mood returns quickly, perhaps in greater force,upon the individual's dawning self-awareness of the“damage done” via the binge and subsequent feelings ofguilt and shame. In this way, binge eating itself might beconsidered an ineffective coping strategy for pre-bingenegative affect, thus explaining the increase in negativeaffect post-binge. Regardless of the time length of relieffrom negative affect that binge eating may provide, theliterature agrees that negative affect often precedes binge
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eating and thatmore research on the role of binge eating tomanage affect is warranted. In summary, data frompreviousresearch linking negative affect as a precipitant for bingeeating, the compelling theory of the affect regulationmodelof binge eating, and the need for further studiesinvestigating the use of binge eating for emotion manage-ment provide foundation for the rationale to incorporateemotion regulation strategies into BED treatments.
Rationale for Development of a GSH BED InterventionBased on Affect Regulation Model
There are then a number of reasons for further study ofand treatment development for a BED GSH treatmentbased on affect regulation model of binge eating. Manyrecent reviews indicate that GSH is a promising treatmentoption for BED (Perkins & Schmidt, 2006; Perkins et al.,2006; Stefano et al., 2006; Sysko &Walsh, 2008; Vocks et al.,2010); however, all call for further GSH research, includingstudies comparing GSH to established interventions orcredible comparison treatments before more steadfastconclusions are drawn.While GSH is typically administeredon an individual basis, group-based GSH offers a novel,viable, and even more cost-effective alternative, althoughfew studies in the literature were found that administeredCBT-gsh in group format (Peterson et al., 1998; Petersonet al., 2001; Peterson et al., 2009). Last, to the writer'sknowledge, no existing BED GSH treatment has incorpo-rated an affect regulation model of binge eating, whichappears warranted given research linking negative affectand binge eating (Abraham & Beumont, 1982; Arnow,Kenardy, & Agras, 1992, 1995; Polivy & Herman, 1993).Moreover, data linking negative affect with the onset ofbinge eating episodes supports the utility of affectregulation models of binge eating in intervention theoryand application.
Integrative Response Therapy—A New GSH BEDIntervention
Integrative Response Therapy (IRT) is a group-basedGSH treatment program for BED that is primarily based onaffect regulation theories of binge eating, while addingemphasis on cognitive restructuring techniques, reducingvulnerabilities and, when possible, negative events thatcontribute to problematic emotional responding andcognitions. The IRT model (Figure 1) postulates atheoretical pathway leading to and maintaining bingeeating, and intervention areas to target in order to reducethe frequency of binge eating.
IRT Model Components
The core factors, also intervention points, in the modelinclude: vulnerabilities, events, interpretations, emotions,and emotion coping strategies.
Vulnerability refers to being overly susceptible to anyfactor that could increase the risk of negative or unpleasantemotions, and therefore binge eating. IRT offers specificinterventions for reducing common vulnerabilities inaddition to general emotion coping strategies (describedbelow) that are readily applicable to vulnerabilities.
Events are incidents that lead to subsequent interpreta-tion and emotional response. Events can be external (e.g.,argument with spouse, flat tire, hard day at work), internal(e.g., a headache), or a behavior (e.g., oversleeping, yelling,binge eating, being late to work). Events can be related toone another and/or occur in sequence and thus be additivein their impact on interpretations and emotions (e.g., tardyto important work meeting, forgot laptop with a presenta-tion on it, and spill coffee on shirt). Vulnerabilities canincrease the chance of a negative event and vice versa. Inorder to reduce the likelihood of unnecessary negativeemotions and binge eating, IRT describes methods for(a) reducing negative events when possible, (b) improvingmanagement of negative events when they do occur, and(c) increasing positive events.
Interpretations represent how one ascribes meaning orsignificance to an event, or summarizes the experience ofan event. Thus, they often occur after an event (althoughsome interpretations may begin during an event). In-terpretations and emotions have a cyclical relationship asthey directly and repetitively influence each other. IRTteaches strategies to change overly negative and globalinterpretations into more accurate reflections in order toreduce unnecessary and unwanted negative emotions andthereby binge eating.
Emotions are affective responses accompanied by aphysiological, often behavioral, and/or interpretive re-sponse. Again, IRT postulates that emotions have a directand reciprocal influence on interpretations, are impactedby vulnerabilities and events, and are antecedents to anemotion coping strategy.
Emotion Coping Strategies can be any method, active orpassive, constructive or potentially destructive, an individ-ual employs to deal with (e.g., cope, avoid, distract, face) anemotion. Examples include: binge eating, drinking, avoid-ance, berating oneself, procrastination, excessive shopping,smoking, sleeping, being rude or testy with others, orseeking support, talking to a friend or therapist, exercise,addressing the problem head on, meditation, and relaxa-tion. As the IRT model depicts, there is a direct reciprocalinfluence between emotion coping strategies and emo-tions. Thus, IRTemphasizes that using a destructive strategy(e.g., drinking, instigating arguments, binge eating) is likelyto increase negative emotions and further risk of (addition-al) binge eating. Likewise, supplementation of a destructivestrategy with a constructive one (e.g., seeking support,talking it through, soothing) will decrease both additionalexperience or exacerbation of negative emotions and
Figure 1. Integrative Response Therapy Model.
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further risk of binge eating. Emotion coping strategies arealso a subtype of event and thus can retrigger the entirecycle via emotions and interpretations and/or vulnerabil-ities and events (as indicated by the direct and arc arrows inmodel). IRT offers (a) various active and constructiveemotion coping strategies, and (b) emotion induction andreexperiencing techniques to prompt use of such copingstrategies to facilitate the replacement of binge eating withalternative, more effective emotion management tools.
RESPONSES is an acronym that represents the IRTemotion coping strategies: Reflect on alternative interpre-tations, Exercise, Start distracting, Problem solve, Opencommunication, get distaNce, Soothe, get cEntered, Socialand/or pleasurable activity. Group participants are taughtthe specifics of how to apply these techniques, and usegroup to discuss triumphs and problem solve aroundbarriers to success. The rationale for teaching emotioncoping strategies is to offer behavioral and cognitivealternatives to binge eating that participants may notknow or have previously underutilized.
Advanced Emotion Coping Training is an advancedemotion regulation technique in which participants are
taught how to purposefully induce and experience anemotion and then work to reduce it via application ofRESPONSES (which have been previously mastered). Bycreating these emotional experiments, participants fashiona situation that may have otherwise induced binge eatingbut now, in a controlled premeditatedmanner within a safeenvironment, they have an opportunity to apply moreeffective and healthful coping strategies. Benefits of thistechnique include (a) increased insight into which specificemotions may be one's most troublesome triggers for bingeeating, (b) improved familiarity, level of comfort with, andmastery of using the RESPONSES strategies with a real-timeemotional experience, (c) principal establishment of andconfirmation that one can successfully use alternativehealthful methods aside from binge eating to cope withaversive emotions, and thus, (d) improved self-efficacy andmotivation for binge eating cessation. The rationale foremotion induction and reexperiencing training is (a) basedin evidence from the anxiety literature that this type ofinduction and exposure exercise coupled with previouslymastered anxiety reduction techniques has resulted inreduced intensity and frequency of subsequent anxiety
97Integrative Response Therapy for BED
and/or improved ability to effectively manage anxiety infuture similar situations; and (b) that it is an interventionconsistent with IRT as an affect-regulation-based model.
Session Format
IRT's10 group sessions last 60 minutes each and areadministered over the course of 16 weeks with the first 4sessions occurring weekly and remaining 6 sessions biweekly.IRT's first 6 and last 2 sessions are structured (i.e., includeworksheet review and teach newmaterial) in order to ensurereview and encourage discussion about important conceptsat the outset and cessation of treatment. IRT's 6th and 7thgroup session topics are “participant driven” or determinedby questions and problems raised independently by partic-ipants. The rationale for these two group session topicsbeing participant- rather than therapist-determined isthat it reinforces the GSH nature of the treatment via(a) compelling participants to be relatively independent andtake an active lead role in facilitating their own recovery frombinge eating, (b) decreasing reliance on the therapistto generate discussion and identify problem areas, and(c) encourage reliance upon the treatment manual ratherthan the therapist. Thus, participants are encouraged tobring their questions and concerns (e.g., regarding IRTconcepts, skill application, barriers to success, and work-sheets) to group for discussion. Forpilot testingpurposes, thegroup therapist was this writer; however, IRT was designed tohave all group therapy sessions led by non-doctorate-degreeholding therapists (with bachelor's, associate's, or a master'sdegree) who do not have specialty training in eatingdisorders.
Session 1 (Week 1): Welcome, Discuss the Pros and Cons ofStopping Binge Eating, Introduce IRT Model
The purpose of Session 1 is to welcome and introducethe groupmembers to eachother, discuss participants’prosand cons of stopping binge eating, and orient the partic-ipants to IRT and the nature of a GSH treatment program.Participants are given the IRT manual and instructed tocomplete the “Identifying Pros andCons of Stopping BingeEating” worksheet in Session 1. Participants’ responses onthe worksheet are then collaboratively discussed—thepurpose of which is to increase motivation for treatmentcompliance while acknowledging the role binge eating hasserved in their lives. The therapist introduces the IRTmodel and applies participant-provided binge episodeexamples to model. Last, participants are instructed toread the entire manual prior to Session 2.
Sessions 2–6 (Weeks 2–8): Teach the IRT Model and ChangeStrategies
The therapist introduces and describes each componentof the IRT model, interventions related to each modelcomponent, and elicits and applies participant-providedbinge episode examples to the model in order to highlight
the model's personal relevance and the reinforcing natureof binge eating. Didactics for Sessions 2–6 includeRESPONSES, Advanced Emotion Coping Training, events,vulnerabilities, and a comprehensive review integrating allcomponents, respectively.
Sessions 7–8 (Weeks 10–12): Participant ChoiceSession topics are determined by participants. Topics
may be related to the IRT model of binge eating (e.g.,emotions, interpretations, vulnerabilities), concept clarifi-cation, barriers to effective and timely use of IRTtechniques, efficient use of worksheets, and generalproblem-solving (e.g., how to eat in social situations).
Session 9 (Week 14): Review/Sticking With What WorksThe 9th session provides a structured and comprehen-
sive review of IRT's concepts and techniques. The therapistalso encourages participants to identify patterns in theirbinge eating and IRT technique use, and continue regularuse of IRT methods they have found most helpful.
Session 10 (Week 16): Planning Ahead/Relapse PreventionThe final session offers techniques for success mainte-
nance via planning ahead and relapse prevention, andeffectively and swiftly coping with lapses.
IRT Group Therapy Illustrations: Transcription ExcerptsFrom Sessions 1 and 3Session 1: Therapist Introduces the IRT Model
Note: In this session the therapist describes the IRTmodel from the bottom-up (i.e., from coping strategy up tovulnerability); the IRT Model is depicted in Figure 1.
THERAPIST: Let's talk now about the IRT model.Overall, what we are looking at here is the relation-ship between negative emotions and bingeing as away to cope with them. Let's draw this out on theboard [draws]. First, at the bottom of the model is“coping strategy,” so let's put “binge eating” here as itis an example of a coping strategy that we'll focus onas a core part of this treatment.Now, let's see nowhowthis model works with an example of someonepreparing for a job interview. So let's say this personis experiencing anxiety [points to emotions section ofmodel] as a negative emotion, and uses bingeing to tryto reduce that feeling or ignore it.
Also, there is a very important relationshipbetween our feelings and the way we think, called“interpretations.” For example, this person's inter-pretations that impact the emotion of anxiety mightbe "I'm going to fail; this interview will be terrible."Can you notice that if this person thinks this way thatthey're likely to feel more anxious?
GROUP MEMBERS: [collectively] Sure. Yes.
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THERAPIST: Right. Now as this person is feeling moreand more anxious, what types of interpretationsmight they be having?
GROUP MEMBER 1: More of the same—like a viciouscycle.
THERAPIST: Right—exactly. The interpretation “I'mgoing to fail” and the feeling of anxiety feed eachother in a vicious cycle. So these two things reallyinfluence each other a great deal [points to reciprocalinteraction between emotion and interpretations on board].Therefore, the interpretations also influence thecoping strategy of binge eating down the line [points tothis relationship, as depicted in arrows, in the model ]. Boththe emotions and interpretations can influence thecoping strategy.
There is an event that happens before there is theinterpretation and emotion. So, in other words, youare interpreting something; the thoughts result fromsome source. In this example, the person is going tohave a job interview.Has everyone here had some typeof interview? They can be kind of nerve-racking, right?This person's event is the job interview, he or she hasinterpretations “I'm going to fail” which increasesanxiety and additional critical interpretations and,ultimately, this person is more and more likely to dealwith the anxiety via binge eating [correspondingly pointsto each factor in the model and highlights the interactionbetween factors]. Is this sounding familiar? Does itresonate with folks?
GROUP MEMBERS: [collectively] Yep. Yes.
THERAPIST: There is another part to this model.Even before the event, we believe that there is avulnerability that exists [points to vulnerability]. WhenI say vulnerability—well, it means just what itsounds like. It refers to something that sets youup to have a harder time than you might normallyor otherwise. An example of vulnerability in thiscase is that the person is really tired. If you're reallyexhausted, how does that impact your ability tocope with something, like a job interview, thatmight normally be really hard?
GROUP MEMBER 2: It makes it harder.
THERAPIST: Yes, it reduces your ability to handle thesituation as you might ideally like or makes doing soharder overall. [Therapist then reviews the definition andflow of model factors again, using the job interview example].So, what do you guys think? We're not completely
done yet, by the way, but we've covered the first corepart of the model. How does it sound so far?
GROUP MEMBER 1: Unfortunately, it sounds veryfamiliar.
GROUP MEMBER 3: Yeah, like my life. I mean, I don'tthink you always think clearly about these things andcan identify how you're vulnerable, interpreting, etcetera. I think stuff happens and this [points towardmodel ] is the breakdown of it. [Right now] I think wefeel like we're along for the ride; like I'm powerlessand the inevitable end is bingeing.
THERAPIST: That is an excellent point that leads meinto talking about why we are breaking it down likethis. Do you guys have any ideas about why it wouldbe helpful to take something that feels like “it's justhappening to you” and break it down like this, intomore understandable pieces?
GROUPMEMBER 2: Well, there are a couple of differentplaces where you can try to stop it. Right?
THERAPIST: Great point. Can you give us an example?
GROUP MEMBER 2: Well, I see you could come up witha different coping strategy. Which I think, probably,we all have tried. And so, um, you know, you couldprobably come up with different interpretations or… How can you make that arrow go in a differentdirection [points to board ]? How could you, youknow, insert something else there?
THERAPIST: OK, like inserting something else forinterpretation and see how it impacts the rest?
GROUP MEMBER 2: Yeah, exactly. Then, we're alwaysgoing to have events. We are always going to putinto a vulnerable position and we're always going tohave an emotion…
THERAPIST: I want to jump in here if I can. I hear whatyou're saying and everyone seems to be getting to oneimportant point which is, yes: there are multipleplaces to intervene. And I heard you saying that youare “always going to have events and vulnerabilitiesand emotions” but we can do certain things tointervene at every single level in the model. We aregoing to spend this treatment looking at how we canimpact all these different things. Hopefully thatprovides, even though this is a vicious cycle, somefaith and hope that there are many different ways to
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address this problem [points to binge eating on board ].And I think that's a really good thing!
What I haven't done yet is draw these arrows frombinge eating back up to the other factors [draws onboard]. So it doesn't just end in binge eating but rathercomes back up and influences in the other direction.Someone earlier mentioned that they feel guilty aftera binge or think, “Oh God, what did I do?”
GROUP MEMBER 4: Yes, there should be an arrow frombinge eating back up to anxious.
THERAPIST: Yes! Absolutely, in fact there is abidirectional arrow in between emotions and bingeeating and interpretations and binge eating. That'sa very important point. Also, the arrow goes back upto the event [points to arrow from interpretations andemotions back up to event]. Using our example: if yougo into an interview thinking “I'm going to fail,”how do you think the actual interview is going togo?
GROUP MEMBERS: [collectively] Not good. Bad.
THERAPIST: Yes, probably not very well. So there isanother arrow here for that. If you have this kind offrustrating job interview and it's going to wear youdown, then you might be even more vulnerable to asubsequent event. That's why we have this arrowhere [points to arrow from event back up to vulner-ability]. So this is another really important point—these factors all play into each other.[Therapist moves on to discuss additional model attributesand apply participant-provided binge examples to themodel].
Session 3: Advanced Emotion Coping Training
THERAPIST: Advanced Emotion Coping Training [isan emotion regulation exercise that] asks you to,step-by-step, imagine yourself in a situation thatheightens an emotion that triggers binge eating foryou. And then to do something different instead ofbingeing. Try using some of the RESPONSESinstead. So this will challenge you. It will really helpyou build your confidence that you can use theRESPONSES, that you can do something differentthan binge eating in response to these emotions,prove to you that you know how to do it, and it canmake you really feel good about yourself.
I'll walk you through it step-by-step and it's also inthe book on page 28. First, Step 1 is to rank youremotions. Find out which are the most triggering foryou. And Worksheet 3 is going to be helpful for that.
That's where you listed the emotions that tend totrigger binges or binge urges, and at which level ofintensity [from 0, not present at all, to 10, the most intensefeeling possible]. [For example] my number-one emo-tion is boredom. My number-two emotion is anxiety.Boredommight be at an 8 for intensity, anxiety at a 6.The idea is to pick an emotion and intensity level thatallows you to be successful at this exercise. We want itto be challenging enough, but not so challenging thatit feels overwhelming. Challenging enough so that itfeels like you can actually do it. Later on, once you getthe hang of this, and you feel a little more confidentin how to do the exercise, you can crank it up andinduce the [more intense] emotion.
Step 2 is to Set the Stage. So you'll pick where to doit. At first, when you're just learning how to do this, it'sbest to not do it around food. Do it maybe in the parkor your parked car. Or, um, maybe even on a walk ifyou can focus like that. Or in your bedroom. Some-where away from access to food or where it's harder toget to that food. Also, you're going to pick when to doit. This is really individual. Some people take a half anhour anddo that, and that's fine. But somepeoplemayneedmore time todo it. So really think about when is agood time in your day to do this. But you'll needenough time to imagine a scene, induce the emotion,allow yourself to experience the emotion, and thenuse RESPONSES to bring down that emotion.
The next step is actually inducing the emotion.There's a couple of ways to do this. One is using yourmemory of a specific event. So maybe the time my catwas lost, and that mademe feel distressed and sad andworried. And I can remember what kind of day it was.Maybe it was in the evening; maybe it was around thistime of year. And I can picture where I was, what I waswearing, and maybe any sensations I had at that time.[These specifics] will help you get into that moment alittle bit more. The more I can remember about thatevent, themore realistic it will be. Themore easily I willexperience the same emotion that I did at that time.Wewant to induce some of those emotions,maybe nottoo intense at first, but wanting to feel the emotionassociated with that memory
GROUPMEMBER 1: But not necessarily an emotion at a10 intensity?
THERAPIST: Right. So picking what memory it's goingto be is really important.
GROUP MEMBER 1: And then doing something…
GROUP MEMBER 2: And then feel it, then what? Thenwhat?
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GROUP MEMBER 1: You do something different,besides going into the kitchen.
GROUP MEMBER 3: Then you use one of these[RESPONSES] on page 27.
THERAPIST: Yes. All of those [RESPONSES] are optionsyou can use. Also, if you don't have a memoryconnected with the emotion you are trying to induce,you can read [the examples on] page 30 and that willhelp you [induce an emotion]. But we do encourageyou to try to draw from your own experience becausemore likely that's going bemore effective in inducingthe emotion. But [reading] these examples are anoption as well.
So, you'll also need to plan out which RESPONSESyou're going to use to effectively cope with, sit with,and reduce the emotion after you've induced it. Forexample, I sit in the park and I imagine the timemy catwas lost, I want to know what I'm specifically going todo to help myself feel better. Maybe it will be mind-fulness, maybe it will be taking a walk, maybe it will becalling a friend. I want a few options of things that arelikely going to makeme feel better. So that I have it allplanned out. Do these steps make sense to everyone?
GROUP MEMBERS: [collectively] Yes. OK.
THERAPIST: So, again, you're actually going to bringan emotion up to whatever level you want it to beusing either your memory or the examples on page30. Then you're going to tolerate it there at thatlevel without letting it go any higher, then you'regoing to bring it back down again by doingsomething new, like the RESPONSES.
Last, you're going to reflect on how it went.Worksheet #6 will help you do that. [For example],was it hard to bring the emotion up or bring it backdown?Maybe you picked an emotion that wasn't quitehigh enough and you didn't really feel much. Ormaybe you picked one that was too high and it wasoverwhelming. And then you're going to bring [thecompleted worksheet] into group. And we're going todiscuss how it went.Also, remind yourself of the reasons to do this—it'sgoing to increase your mastery of RESPONSES, it'sgoing to help build confidence that you can reducean uncomfortable emotion without binging. It's apretty powerful technique. It will really make adifference for you if you figure out how to use it ina way that works for you.
Let's think about some things that might get in theway of potentially practicing this week. What do
people anticipate getting in the way of trying this ormaking this hard?
GROUP MEMBER 4: Kids.
THERAPIST: What about kids? Will you need sometime away from them to do this exercise? But youcould also use them as part of your RESPONSES [tobring down the emotion]—play with them, takethem somewhere fun, laugh with them. What else?
GROUP MEMBER 2: Procrastination.
GROUP MEMBER 3: Overwhelmed. Not that I'm notgoing to do it but…
THERAPIST: So let's think of what can we tellourselves to increase motivation to do this?
GROUP MEMBER 3: It's a way to getting to the endproduct that we want.
THERAPIST: That it will help, basically.
GROUPMEMBER 4: I think I'll get stuck in the emotion,rather than move through the emotion.
THERAPIST: If you're worried about getting stuck, Iencourage you to start with an emotion that is lesschallenging for you, that feels less overwhelming,and really plan out what [RESPONSES] to do.Really think about what you're going to do. Whathas worked in the past besides bingeing, to helpyou calm down and feel better? Maybe you needone of the RESPONSES that's more powerful interms of distracting you. I don't know what it will bethat works best for you. What works for you usually?
GROUP MEMBER 4: That's why I'm here. Not a lotworks. [laughs]
THERAPIST: Okay so maybe you need to practice afew more of the RESPONSES before you start theAdvanced Emotion Coping exercise. Maybe youneed to practice and discover which of theRESPONSES will really work for you. Maybe callinga friend that you know will listen. And then havinga backup plan in case she doesn't answer, right?Okay what else might get in the way of trying this?
GROUP MEMBER 4: I don't even feel emotions some-times. I've been through enough things in life that
101Integrative Response Therapy for BED
I'm sorry to say, and so it's really shut me down.That's going to get in the way.
THERAPIST: So you're worried that you're not goingto [successfully] induce [and feel] the emotion? Ifyou're worried about that, you could use theexamples in the book and really pay attention to[sensations in] your body and your interpretationsabout the emotion. So you might want to lookthrough these [examples] and see which can help.What else might get in the way?
GROUP MEMBER 2: Part of me loves being unconscious.And bingeing is a manifestation of being uncon-scious. And these exercises, I can feel, are trying to fixmy brain. And part of me is grateful for the manual,and part ofme is like it's taking awaymy blanket. NowI have to think about these things. It's like restructur-ing my brain. Where previously, the whole beauty ofthe binge is to go into a food cloud, and becomeunconscious.
THERAPIST: Yes, you're right—I think you're sayingits hard work? [It may help to review]: What is mymotivation for wanting to change? What are thepros and cons of change? That will help you face allthe things that get in the way of trying this thingthat is hard work. This is new. We are making youthink about it.
Novel Aspects of IRT
While IRT integrates important therapeutic aspects ofaffect dysregulation theories of BED that are similar toDBT-BED and cognitive restructuring techniques that aresimilar to traditional forms of CBT (i.e., CBT fordepression), it also has numerous novel aspects. IRT is anaffect-regulation and group-based GSH BED interventionthat primarily focuses on emotional interventions for bingeeating cessation yet integrates cognitive and behavioraltechniques. It teaches emotion induction and reexperien-cing to prompt use of effective emotion coping responses.This augments participants’ self-efficacy and establishesexperience in responding to aversive emotions healthfully(i.e., without binge eating). In addition, IRT ismultifaceted;it teaches techniques for (a) binge antecedents (i.e.,reducing vulnerabilities to overwhelming emotions andfaulty cognitions,managing binge urges, andwhenpossible,reducing negative events) and (b) binge repercussions(improving emotional, cognitive, and behavioral responsesto binge episodes). At the same time, IRT offers a modelreadily applicable to psychological concerns aside frombinge eating (e.g., interpersonal disputes, anxiety, etc.).
Unlike most existing treatments that were originallydesigned for another psychiatric or medical concern (e.g.,
CBT and IPT for depression, DBT for borderline person-ality disorder, BWL for weight loss), IRT is designedspecifically for BED; and unlike existing specialized BEDtreatments (e.g., CBT, IPT, or DBT-BED), IRT is designedto not require a specialty trained therapist or time-intensiveadministration (e.g., 6 months of up to 2-hour weeklysessions to administer). Finally, via the GSH format, IRTworks to deliberately and simultaneously decrease partici-pant reliance on therapist and encourage participants totake an active lead role in the recovery process (i.e.,participant determines where they need assistance ratherthan relying on therapist to make a suggestion or direct allsessions).
Similarities and Differences Between IRT and Other BEDTreatment Approaches
IRTand otherwell-known treatments share componentscommon to many therapeutic approaches for BED (e.g.,CBT, IPT, DBT-BED) including: manual-based, focus oncessation of binge eating, therapist is active and directive insession, import placed on rapport between therapist andpatient, homework (in the form of behavioral tasks and/orworksheets) is encouraged, therapy sessions include bothreflective and didactic/psychoeducational components,and motivation and relapse prevention are addressed.
IRT and CBT-gshCBT-gsh is a frequently used, manual-based form of
GSH that has demonstrated efficacy. As originally concep-tualized by Fairburn (Fairburn, 1995), CBT-gsh typicallyoffers participants a book on overcoming binge eatingaccompanied by 6 to 12, approximately 30-minute,individual therapy sessions (Carter & Fairburn, 1998;Grilo & Masheb, 2005). IRT and CBT-gsh differ in theirtheoretical postulates of primary and secondary bingeeating precipitants and, consequently, in their type andsequence of interventions to achieve abstinence. Suchdistinctions may yield significant differences in bingeeating abstinence rates and patient acceptability. WhileIRT postulates that binge eating is primarily an attempt toalter, avoid, suppress, or otherwise cope with aversiveemotions and/or faulty cognitions, CBT-gsh proposes thatbinge eating results from behavioral factors, specificallyproblematic eating patterns. This key theoretical distinc-tion accounts for the differences in intervention focus andsequence of the two treatments. Specifically, IRT firstworks to teach effective emotion coping and cognitiverestructuring, while CBT-gsh primarily focuses on rectify-ing behavioral triggers of binge eating (i.e., eliminatingdietary restriction and establishing regular patterns ofeating). Secondary intervention targets for IRT includevulnerability reduction and negative event management,whereas CBT-gsh addresses concerns about food, weight,and shape. IRT, therefore, does not require the regular
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self-monitoring and behavioral modification of foodintake that is the crux of CBT-gsh. CBT-gsh, unlike IRT,does not directly provide emotion coping strategies forovercoming urges to binge eat. In summary, IRT and CBT-gsh differ in their theoretical postulates of primary andsecondary binge eating precipitants and, consequently, intheir type and sequence of interventions to achieveabstinence.
IRT and DBT-BEDWhile both IRT and DBT-BED acknowledge binge
eating as an attempt to alter aversive emotional states andpostulate that binge eating is maintained via negativereinforcement, or the temporary relief from unpleasantemotion, there are some critical therapeutic differencesbetween the two treatments. First, IRT is a GSH treatmentandDBT-BED is a specialty treatmentwhose administration(as detailed in Safer et al., 2010) requires a Ph.D.-leveltherapist and up to 6 months of 2-hour sessions toadminister. Unlike DBT-BED, IRT places therapeuticemphasis on emotions and/or cognitions as binge eatingprecipitants and therefore places greater weight oncognitive restructuring techniques. IRT purposefully pro-vides substantially fewer skills than DBT-BED in order tostreamline teaching and reduce patient burden warrantedwithin the shorter treatment delivery time frame. IRTteaches emotion induction and reexperiencing to promptuse of effective emotion coping responses and DBT-BEDdoes not. IRT does not employ chain analyses and diarycards characteristic ofDBT-BED. Last, IRTdoes not requirethe commitment to 100% binge abstinence obtained fromDBT-BED participants in Session 1.
IRT and IPTIPT's theoretical basis is quite different from IRT's as
the former conceptualizes each case within one of foursocial domains (grief, interpersonal role disputes, roletransitions, and interpersonal deficits) and then directlyaddresses these social and interpersonal deficits to reducebinge eating. IPT is not based on an affect-regulationmodel of binge eating, nor does it provide direction incognitive restructuring.
Method
Anuncontrolledpreliminary study of IRTwas conductedto test the feasibility of recruitment, treatment, patientadherence, and patient acceptability.
SubjectsA small sample of adults (n=16)meetingDSM-IV criteria
for BED participated in the study. Participants wererecruited through flyers and clinic referrals for “treatmentfor binge eating.” Eligibility was assessed via an initialtelephone screen followed by an in-person clinical inter-view, during which potential participants provided in-
formed written consent. Men and women aged 18 andolder who met DSM-IV research criteria for BED and livedor worked within commuting distance of the clinic wereincluded. Exclusionary criteria were as follows: (1) concur-rent psychotherapy treatment; (2) unstable dosage ofpsychotropic medications over the three months prior toinitial assessment; (3) regular use of purging or othercompensatory behaviors over the past six months; (4) psy-chosis; (5) current alcohol/drug abuse or dependence;(6) severe depression with recent (e.g., within past month)suicidality; (7) current use of weight altering medications(e.g., phentermine); (8) severemedical condition affectingweight or appetite (e.g., insulin dependent diabetes, cancerrequiring active chemotherapy); (9) current pregnancy orbreast feeding; (10) imminently planning or undergoinggastric bypass surgery; and (11) lack of availability for timesof group meetings and/or duration of study. The study wasreviewed and approved by the Institutional ReviewBoard ofStanford University Medical Center.
AssessmentParticipants were asked to complete three assessments
(baseline, posttreatment, and 3-month follow-up). Theassessment battery was the same at all time points andincluded the Eating Disorder Examination Questionnaire(EDE-Q; Fairburn & Beglin, 1994), Beck DepressionInventory (BDI; Beck, Ward, Mendelson, Mock, Erbaugh,1961), Emotional Eating Scale (EES; Arnow et al., 1995),and Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1979).Body weight was assessed on a balance beam scale, with theparticipant in lightweight clothing and shoes removed.Height was measured with a stadiometer. For both vari-ables, the average of two measurements was used. BodyMass Index (BMI) was calculated as weight (in kilograms)divided by the square of height (in meters). A satisfactionsurvey was administered at posttreatment to assess patientacceptability of treatment.
TreatmentAll participants received IRT. Group sessions followed
the aforementioned outline.
AnalysisDescriptive analyses were used to summarize the sample
characteristics and outcomes. T-tests, using completeranalysis, tested differences on outcome measures betweenbaseline and posttreatment and baseline and 3-monthfollow-up. Cohen's d effect sizes, based on Morris andDeShon's (2002) effect size equation for within subjectsrepeated measures (which corrects for dependencebetween means), were calculated for the primary outcome(number of binge days over the previous 28 days). Effectsizes were evaluated by the conventions: small = .20,moderate=.50, and large=.80 (Cohen, 1988).
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ResultsSample Characteristics
The sample consisted of 16 adults, 88% (n=14) female,with a mean age of 51.1±9.9 years and BMI of 31.2±9.4 kg/m2. Subjects were 88% (n=14) Caucasian, 6%(n=1) Latino, and 6% (n=1) Asian. Seventy-five percent(n=12) of subjects were married, 19% (n=3) divorced, and6% (n=1) widowed. Regarding education, 44% (n=7)completed at least one graduate degree, 25% (n=4)completed some graduate school, 19% (n=3) graduatedfrom a 4-year college, 12% (n=2) completed some collegeor a 2-year degree. Over half of the sample was employed(57%, n=9), 19% (n=3) homemakers, 12% (n=2) retired,and 12% (n=2) unemployed. On average, participantswere 17.3±8.8 years old when first overweight, 17.9±7.1 years old when they first began dieting, and 22±12.9 years old when they reported beginning to binge eat.
Treatment and Assessment Dropout RatesOf 16 participants, 4 (25%) dropped from treatment.
Drops occurred after Session 1 (twomen whose reasons fordropping are unknown), Session 2 (because she believedher eating disorder was more advanced than other groupmembers), and Session 4 (because she wanted to focus onweight loss rather than binge eating cessation). Allparticipants who completed treatment completed post-treatment and follow-up assessments (n=12). Althoughparticipants who dropped from treatment were invited tocomplete posttreatment and follow-up assessments, only 1completed posttreatment assessment. Thus, posttreatment
Note. Means in the same row with different superscripts represent statisticabinge episode over the previous 28 days; **number of binge episodesQuestionnaire; BDI=Beck Depression Inventory; Rosenberg=RosenbergIndex.
and follow-up data were obtained from 81% (n=13 of 16)and 75% (n=12 of 16) of the original sample, respectively.
Outcome MeasuresAbstinence rates (defined as zero objective binge
episodes over the previous 28 days) were 54% and 67%at posttreatment and 3-month follow-up, respectively. Thenumber of binge days over the previous 28 days droppedsignificantly from baseline to posttreatment [14.44(±7.16) to 3.15 (±5.70); t =7.71, pb .001; d=2.2] andfrom baseline to follow-up [14.44 (±7.16) to 1.50 (±2.88);t=5.64, pb .001; d=1.7]. All subscales from both the EDE-Qand EES demonstrated consistent decline from baselineto posttreatment to follow-up. There were no significantchanges in BDI or RSE scores, nor in weight or BMI.Posttreatment satisfaction survey data indicated that100% of participants (n=13: 12 who completed treat-ment plus 1 who dropped) would recommend theprogram to a friend or family member in need. Table 1outlines study results.
Discussion
BED, a chronic condition characterized by a combina-tion of eatingdisorder pathology, co-occurring physical andpsychiatric conditions, impaired psychosocial functioning,and association with overweight and obesity, is an eatingdisorder of clinical severity and a significant public healthproblem. GSH treatments for BED appear promising intermsof their capacity for public health impact. Specifically,GSH may be more readily disseminable to health care
lly significant differences (pb .05); *number of days with an objectiveover the previous 28 days; EDE-Q=Eating Disorder ExaminationSelf-Esteem Scale; EES=Emotional Eating Scale; BMI=Body Mass
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providers and accessible to patients than efficaciousspecialty treatments such as CBT and IPT given the latter'sadministration costs and time requirements. This isparticularly important in light of recent data indicatingthe equivalence of CBT-gsh to IPT in remitting BED andassociated symptoms (Wilson et al., 2010).
IRT, a new group-based GSH BED treatment, is basedon the affect regulation model of binge eating and thusprimarily works to decrease binge eating by enhancingemotion coping skills. IRT's secondary focus is oncognitive restructuring and reducing vulnerabilities thatrisk emotional overwhelm and problematic cognitions.IRT demonstrated preliminary evidence for significantlyreducing binge episodes, and all EDE-Q and EESsubscales, at 16 weeks posttreatment within a sample of16 adults. Large effects were observed for reductions inbinge days over the previous 28 days from both baseline toposttreatment (d=2.2) and baseline to 3-month follow-up(d=1.7).
Limitations of the present study should be noted. First,although IRT is designed to be administered by a non-specialty-trained therapist, a Ph.D.-level and specialty-trained therapist (this author) conducted therapy for thepurpose of the present preliminary study. Thus, furtherdata on IRT feasibility and efficacy when administered bya non-specialty-trained therapist is warranted. Second,confidence in findings may have been strengthened withthe use of a structured clinical interview (e.g., the EDE)for major outcome variables instead of the EDE-Q. Third,data on response to treatment and treatment acceptabilityamong those who dropped from treatment is limitedgiven that only 1 of 4 participants who dropped fromtreatment completed a follow-up assessment and treat-ment satisfaction questionnaire. Also, confidence ininferences from statistical analyses is limited given thesmall sample size of the preliminary study. Study strengthsinclude the development of and first iteration ofinvestigation into a GSH intervention for BED based onaffect-regulation models of binge eating, that is deliveredin a relatively non–time intensive fashion. Also, despitethe small scope, sample size and assessment battery, thestudy used well-validated and reliable self-report measuresof outcome variables, and gathered 3-month follow-updata. All participants who completed treatment complet-ed both posttreatment and 3-month follow-up assess-ments. Last, the present study's 25% dropout rate is withinthe range of 13% to 30% previously reported from BEDtreatment studies employing GSH (Grilo &Masheb, 2005;Perkins et al., 2006; Stefano et al., 2006; Striegel-Moore etal., 2010; Wilson et al., 2010).
Investigation of the longer-term effects of IRT within alarger sample, and whether IRT leads to improvements inparticular subgroups, is presently under way in an initialNIMH-funded randomized clinical trial.
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This work received funding from the National Institute of MentalHealth: T32 Ruth L. Kirschstein National Research Service Award forPostdoctoral Research Training T32MH019938.
Address correspondence to Athena Robinson, Ph.D., Departmentof Psychiatry and Behavioral Sciences, Stanford University School ofMedicine, 401 Quarry Road, Stanford, CA 94305-5722; e-mail:[email protected].
Received: November 8, 2011Accepted: February 29, 2012Available online 15 March 2012
