Person-Centered & Experiential Psychotherapies, 2014

Vol. 13, No. 4, 278–293, http://dx.doi.org/10.1080/14779757.2014.910132

Emotion-focused therapy for eating disorders: enhancing emotional

processing
Iryna Ivanova* and Jeanne Watson

Ontario Institute for Studies in Education, University of Toronto, Human Development, and Applied
Psychology, Toronto, ON, Canada
(Received 4 February 2013; final version received 26 March 2014)

Current literature highlights the importance of emotion in the development and main-
tenance of eating disorders. Deficits in emotional processing skills in this population
have been supported by numerous studies. The cycle of bingeing, purging, and
starving are believed to be some of the maladaptive mechanisms of gaining control
over inchoate affective experiences in clients with eating disorders. The first goal of
this article is to present a review of the emotional processing characteristics and
deficits in individuals with eating disorder who either engage in dietary restriction or
binge-purge behaviors. Secondly, an emotion-focused therapy: the process-experiential
approach is proposed as a suitable treatment to address these deficits. Specific emo-
tion-focused interventions that address the ways clients learn to regulate their emotions
are discussed along with the potential challenges of working with eating disorders.
Suggestions for overcoming these challenges using an emotion-focused therapy are
presented.
Keywords: emotion-focused therapy; eating disorders; emotional processing;
emotional expression

Emotionsfokussierte Therapie für Essstörungen: emotionale Prozesse

verbessern
Die aktuelle Literatur unterstreicht die Wichtigkeit von Emotion bei der Entwicklung
und Aufrechterhaltung von Essstörungen. Zahlreiche Studien ergaben bei dieser
Personengruppe Defizite in der emotionalen Verarbeitung. Man vermutet, dass der
Teufelskreis von Essanfällen, Erbrechen und Hungern zu den maladaptiven
Mechanismen bei essgestörten Klientpersonen gehört. Diese Mechanismen werden
als Versuch betrachtet, so über diffuse affektive Erfahrungen die Kontrolle zu gewin-
nen. Erstens will dieser Artikel einen Überblick über die emotionalen Verarbeitungs-
Charakteristika und-Defizite von Personen mit Essstörungen geben: Man erlegt sich
entweder Diätregeln auf oder steckt in Essanfall-Erbrechens-Verhaltensmustern.
Zweitens zeigt er mit der Emotionsfokussierten Therapie als prozess-experienziellem
Ansatz eine geeignete Vorgehensweise, um solche Defizite zu behandeln. Spezifische
emotionsfokussierte Interventionen werden diskutiert und verschiedene Arten vorges-
tellt, wie Klientpersonen damit lernen, ihre Emotionen zu regulieren. Auch die poten-
ziellen Herausforderungen in der Arbeit mit Essstörungen werden skizziert. Gezeigt
wird auch, wie sich durch den Einsatz einer emotionsfokussierten Therapie mit diesen
Herausforderungen umgehen lässt.

*Corresponding author. Email: Iryna.Ivanova@mail.utoronto.ca

© 2014 World Association for Person-Centered & Experiential Psychotherapy & Counseling
 Person-Centered & Experiential Psychotherapies 279

Terapia centrada en la emoción para desordenes de la alimentación:

mejorando el procesamiento emocional
La literatura actual pone en relieve la importancia de la emoción en el desarrollo y
mantenimiento de los desordenes de la alimentación. Los déficits en las habilidades de
procesamiento emocional en esta población han sido apoyados por varios estudios.
Consideramos el ciclo de atracones, purgas, y ayuno como parte de mecanismos de
inadaptación para lograr control sobre incipientes experiencias afectivas en pacientes
con desordenes alimentarios. La primera meta de este escrito es presentar una revisión
de las características y déficits en los individuos con desordenes de la alimentación que
hacen dietas muy restrictivas o tiene un comportamiento de atracones y purgas. La
segunda meta es presentar una terapia centrada en la emoción: se propone el enfoque
procesamiento-experiencial como un tratamiento adecuado para tratas estos déficits.
Discutimos las intervenciones que se dirigen a las maneras en que estos pacientes
aprenden a regular sus emociones así como también los potenciales desafíos de trabajar
con desordenes en la alimentación. Presentamos sugerencias para superar estos
desafíos usando la terapia centrada en la emoción.

La thérapie centrée sur l’émotion dans les troubles de l’alimentation :

améliorer le processus de traitement émotionnel
La littérature récente met en évidence l’importance de l’émotion dans le
développement et le maintien des troubles de l’alimentation. Pour cette population,
des déficits des compétences du traitement de l’émotion ont été décrits dans nom-
breuses études. Le cycle hyperphagie-purgation-privation alimentaire est considéré
comme faisant partie des mécanismes inadaptés visant à garder le contrôle sur des
expériences affectives inaccomplies chez les clients ayant un trouble de l’alimentation.
L’objectif principal de cet article est de présenter une revue des caractéristiques du
processus de traitement émotionnel et des déficits des individus ayant un trouble de
l’alimentation qui manifestent soit des comportements de privation alimentaire, soit
des comportement d’hyperphagie–purgation. En second lieu, une thérapie centrée sur
l’émotion - l’approche processuelle-expérientielle - est proposée comme traitement
approprié pour aborder ces déficits. Des interventions centrées sur l’émotion, qui
ciblent la manière dont le client apprend à réguler ses émotions, sont discutées
comme des défis potentiels pour le travail avec les troubles de l’alimentation. Des
suggestions pour relever ces défis en utilisant la thérapie centrée sur l’émotion sont
présentées.

Terapia Focada na Emoção para Perturbações do Comportamento

Alimentar: ativação do processamento emocional
A literatura atual destaca a importância das emoções no desenvolvimento e
manutenção das perturbações do comportamento alimentar. Diversos estudos têm
corroborado a existência de um défice nas competências de processamento emocional
nesta população. Crê-se que os ciclos de ingestão compulsiva de alimentos, comporta-
mentos purgativos e supressão da ingestão de alimentos constituem alguns dos meca-
nismos que denotam a incapacidade de os indivíduos com perturbações do
comportamento alimentar tomarem o controlo das suas experiências afetivas primiti-
vas. O primeiro objetivo deste artigo é apresentar uma revisão das características de
processamento emocional e dos défices presentes em pessoas com perturbações do
comportamento alimentar, quer elas adotem comportamentos do tipo restritivo ou
ciclos de ingestão compulsiva de alimentos e de comportamentos purgativos. Em
segundo lugar propõe-se uma terapia focada na emoção, a abordagem pelo processa-
mento experiencial, como sendo adequada para o tratamento destes défices. São
debatidas intervenções específicas focadas na emoção, assim como os possíveis
280 I. Ivanova and J. Watson

desafios ao trabalho com as perturbações do comportamento alimentar. Apresentam-se

sugestões para ultrapassar estes desafios, com recurso à terapia focada na emoção.

Introduction
The role of emotion in eating disorders has become increasingly recognized in under-
standing the etiology and maintenance of eating disorders. A significant body of research
has emerged supporting emotional processing deficits in eating disorders (e.g. Beales &
Dolton, 2000; Bourke, Taylor, Parker, & Bagby, 1992; Cochrane, Brewerton, Wilson, &
Hodges, 1993; De Panfilis, Rabbaglio, Rossi, Zita, & Maggini, 2003). It has been
postulated that abnormal ways of eating are attempts to regulate unpleasant affective
states in individuals with eating disorders (Bydlowski et al., 2005). Addressing the ways
in which clients with eating disorders process their emotions would be an important goal
for therapy in order to alleviate the debilitating symptoms. Troop, Schmidt, and Treasure
(1995) assert that, “treatments that promote the expression of feelings may make con-
tributions to recovery beyond those simply increasing weight or reducing frequency of
bingeing” (p. 156). There have been promising preliminary findings for approaches that
focus on affect regulation, such as Dialectical Behavior Therapy (DBT) and Emotion-
Focused Therapy (EFT) to treating eating disorders (see Hill, Craighead, & Safer, 2011;
Ivanova, 2013; Safer, Telch, & Agras, 2001; Tschan, 2010; Tweed, 2013; Wnuk, 2010).
This paper will review the Emotion-focused approach to working with eating disorders.
The first aim of this paper is to present an overview of emotional processing
difficulties in individuals with eating disorders, demonstrating the differential functions
of restriction and binge-purge behaviors as they relate to emotion processing and regula-
tion. Specific deficits in emotional expression will be highlighted. Secondly, an EFT
approach to address emotional processing deficits and to facilitate emotional change in
core maladaptive emotions will be presented.
There is some evidence that there are more shared features among those who binge
and purge or compensate in other ways (e.g. anorexia nervosa, binge/purge type (AN-BP),
BN and eating disorder not otherwise specified (EDNOS) with binge/purge behaviors) as
compared to those who purely restrict (e.g. anorexia nervosa, restricting type (AN-R) or
EDNOS with primary restriction) (Williamson, Gleaves, & Stewart, 2005). Empirical
evidence suggests that binge eating does not distinguish anorexia nervosa and bulimia
nervosa, given that there are individuals with AN who also engage in binge eating, with or
without the compensatory vomiting (Casper, Eckert, Halmi, Coldberg, & Davis, 1980;
Garfinkel, Molodofsky, & Garner, 1980). Longitudinal studies demonstrate that there is a
tendency for individuals to move between the various types of eating disorders, for
example, developing bulimia following a course of anorexia (see Fairburn, Cooper, &
Shafran, 2003). The evidence for the shared features among the different eating disorder
diagnoses suggests that it is appropriate to understand eating disorders from the function
that the behaviors serve, particularly as it relates to modulating affect (Fox, 2009a). This
paper will discuss emotional processing differences among restrictors and those who
engage in binge-purge behaviors, and ways emotional processing deficits can be
addressed using emotion-focused therapy.

Emotional processing in eating disorders

Recent empirical evidence supports the link between disordered eating behaviors and
emotions, suggesting that eating disorders may be a means to cope with distressing
 Person-Centered & Experiential Psychotherapies 281

emotions (Bydlowski et al., 2005; Cooper, Wells, & Todd, 2004; Stice, Akutagawa,
Gaggar, & Agras, 2000; Treasure, Schmidt, & Troop, 2000). Individuals with ED are
particularly prone to experiencing negative emotions, such as anger, shame, disgust,
fear and sadness, and find emotions overwhelming (Fox & Power, 2009; Waller et al.,
2003). They are threatened by experience of anger and are prone to suppress it (Fox,
2009a; Fox & Power, 2009; Ioannou & Fox, 2009). As a result of this ego-dystonic
relationship with anger, a less threatening emotion, such as shame and disgust toward
one’s own body is generated to inhibit the experience and expression of anger (Fox &
Power, 2009). However, shame is a highly common emotion irrespective of whether
the individual experiences anger. Studies demonstrate that levels of shame are sig-
nificantly more elevated in individuals with eating disorders compared to other
clinical groups (Cook, 1994). In line with Bruch’s (1973) earlier writings, some
suggest that restrained eating may help individuals with ED to distract from feelings
of shame and feel more in control and accomplished, while bingeing may be a
distraction from unpleasant emotional states, images, memories and beliefs (Cooper,
Todd, & Wells, 1998).
Some suggest that dietary restriction and binge-purge behaviors serve different
modulating functions (Fox, 2009a; Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring,
2012). Restricting food is theorized to serve as a strategy to avoid emotions or inhibit
awareness (Fox, 2009b); whereas bingeing and purging is used to suppress emotions
once they have been activated (Cooper et al., 2004; Waller, Kennerley, & Ohanian,
2007).

Emotion regulation in dietary restraint

Qualitative accounts of individuals with anorexia demonstrate that suppression and over-
control of emotions is more common in those with restricting types of symptoms, and was
associated with the tendency to inhibit anger and sadness (Fox, 2009b). However, in some
cases, restriction of food may be associated with increased positive affect (Vitousek &
Ewald, 1993). A sense of euphoria associated with feelings of successfully losing weight
and restraining oneself from eating, having control over one’s body, and attention from
others can have a powerful reinforcing role in anorexia (McCurdy, 2011). Some clients
note a sense of numbness, or a mild sense of dissociation as a result of restricting can be
reinforcing.

Emotion regulation in binge-eating/purging

In contrast to using restriction to pre-empt emotional activation, binge-purge behaviors are
theorized to modulate affect once the emotion has been activated (Waller et al., 2007).
However, the fear associated with weight gain and disgust toward their bodies propels
individuals with bulimic symptoms to compensate via purging, laxative abuse, or exces-
sive exercising. Purging has been found to reduce emotional discomfort and result in a
temporary sense of relief (Mizes & Arbitell, 1991; Polivy & Herman, 1993). Milligan and
Waller (2000) found that bulimic behaviors reduced anger, particularly among those who
have a tendency to avoid expressing it. The binge-purge behaviors appear to help
individuals with ED to dissociate from painful emotions.
282 I. Ivanova and J. Watson

Emotional expression in binge eating/purging and dietary restraint

Evidence suggests that clients with eating disorders are impaired in their ability to
identify and make sense of their emotions (Bydlowski et al., 2005; Taylor, 1997).
Kennedy-Moore and Watson (1999) identified five stages in the process of expressing
emotion that can help illuminate the deficits in emotional processing in ED. The first
stage is the prereflective reaction, which occurs when an individual initially perceives
the stimuli at a preconscious level and may experience bodily changes in response to the
stimuli. The second stage is the conscious perception of the response, which involves
initial awareness of the affective reaction including the physiological reaction, followed
by the third stage, labeling and interpretation of the affective state. The fourth stage is
the evaluation stage during which the person determines whether the feelings are valid
and acceptable. Finally, the fifth stage depends on the perceived social context for
expression with the individual either expressing or withholding the emotion. Clients
with eating disorders are hypothesized to experience difficulties at a number of different
stages of the emotional expression model, which can interfere with adaptive emotional
attunement.
One aspect of these disruptions is due to commonly co-occurring alexithymia (Beales
& Dolton, 2000; Bourke et al., 1992). That is, individuals with ED have difficulty
identifying and distinguishing emotions from physical reactions, putting emotions into
words, and communicating them to others (Bydlowski et al., 2005). Clients with eating
disorders, particularly those who rely on restriction of food, tend to deny awareness of
their physiological reactions to emotions because they find them too threatening (Ioannou
& Fox, 2009). Further, they lack symbolization skills that involve identifying their inner
experience, expressing it in words, attributing meaning to their inchoate subjective
experience (Bruch, 1973). As a result, they may have difficulties adequately engaging
in reflexive self-examination and are often left with a general sense of distress or over-
whelm, rendering them unable to make sense of their experience (Kennedy-Moore &
Watson, 1999). Such undifferentialed feelings can result in intense and uncontrolled
emotional reactions (Bydlowski et al., 2005; Greenberg, 2011), such as sudden crying
or fits of anger, particularly for emotionally underregulated clients who tend to engage in
binge-purge cycles. Alternatively, for those who tend to restrict food, the inability to
differentiate feelings may lead to “numbing out.” Because individuals with ED tend to
avoid their emotional experience in general, they are unable to solve the problems to
which the emotional response is alerting them.
It is common for clients with eating disorders to believe that emotions are dangerous
and should be avoided; thus, it may be difficult for them to accept their emotions (Ioannou
& Fox, 2009). This reflects disruptions in the evaluative stage of the emotional expression
model (Kennedy-Moore & Watson, 1999). A negative view of emotions often develops in
environments where communication about emotion is ignored or responded to negatively
(Corstorphine, 2006; Fox, 2009b). The suppression of emotion is reinforced through
messages like, “no one wants to see your tears” or “just forget about your feelings and
let them go”; this fosters beliefs that emotions are “bad” and should be avoided. As a
result, maladaptive emotional responses may develop that include negative beliefs about
emotions, and binge eating, purging, or food restriction may be substituted for modulation
and expression as a means of coping. Based on empirical evidence of emotional deficits in
this population, an approach that primarily focuses on facilitation of emotional change,
such as EFT, has been suggested as highly suitable (Dolhanty & Greenberg, 2007, 2009;
Greenberg, 2002; Wnuk, 2010).
 Person-Centered & Experiential Psychotherapies 283

Emotion-focused therapy
Emotion-focused therapy is an empirically supported, integrative, experiential approach
for depression (Goldman, Greenberg, & Angus, 2006; Greenberg & Watson, 1998;
Watson, Gordon, Stermac, Kalogerakos, & Steckley, 2003), trauma (Paivio &
Nieuwenhuis, 2001) and for couples in distress (Denton, Burleson, Clark, Rodriguez, &
Hobbs, 2000; Goldman & Greenberg, 1992; Johnson & Greenberg, 1985; Walker,
Johnson, Manion, & Cloutier, 1996). Preliminary results suggest that EFT is effective in
alleviating the frequency of binge-eating and purging, improves emotion regulation, self-
efficacy, psychiatric symptoms, and motivation to change (Ivanova, 2013; Tschan, 2010;
Tweed, 2013; Wnuk, 2010). The adaptation of EFT to eating disorders is timely, given the
widespread recognition of the role of emotion in eating disorders, and the recommenda-
tion by the National Institute of Mental Health (NIMH , 1998) to integrate the regulation
of emotion into psychotherapeutic interventions. Federici and Kaplan (2008) assert that:

…therapeutic approaches that place a greater emphasis on emotion regulation and exploration
of internal affective processes (e.g. Dialectical Behavior Therapy, Emotion-Focused Therapy)
may have important implications for the treatment of eating disorders. (p. 8)

The following discussion provides an overview of EFT theory for ED, followed by
application of EFT interventions to eating disorders.

Emotion-focused therapy for eating disorders

EFT views the development of eating disorder symptoms resulting from an impaired capacity
to access, identify, and be guided by adaptive emotions. Developmentally, these individuals
are often brought up in environments in which emotions were dismissed, avoided, or would be
expressed in unpredictable and uncontrollable ways (Fox, 2009b). As a result, emotional
experiences are perceived as aversive and overwhelming, and engaging in problematic eating
behaviours provides a means to avoid experiencing emotions (Dolhanty & Greenberg, 2007,
2009). Given that different disordered eating behaviours serve a numbing or a regulating
function, EFT aims to process unpleasant emotions by attending to and increasing awareness,
and expression of internal emotional states; learning to tolerate and regulate that experience;
reflect and make meaning of it by symbolizing that experience in words, and transforming
maladaptive emotions by activating healthy, adaptive ones, and their associated needs and
action tendencies (Dolhanty & Greenberg, 2007; Elliott, Watson, Goldman, & Greenberg,
2004; Greenberg & Watson, 2006). Given the identified impairments in emotional processing,
and more specifically, limited awareness, poor recognition and labelling of emotions, diffi-
culties accepting their emotions and inhibited expression (Harrison, Sullivan, Tchanturia, &
Treasure, 2009; Ioannou & Fox, 2009; Svaldi et al., 2012), several EFT interventions that are
highly suitable are discussed in the following section. It is noteworthy that the adaptation of
EFT for eating disorder is in its early stages with preliminary evidence showing promising
results. Future empirical studies evaluating efficacy and the processes of change in EFT would
help pave the way to address the core affective difficulties in eating disorders.

Empathy and the therapeutic alliance

Engaging clients with eating disorders in treatment is frequently cited as a significant
challenge (Vitousek, Watson, & Wilson, 1998). Understanding the private experience of
284 I. Ivanova and J. Watson

clients with eating disorders, empathizing with their distress and acknowledging the
difficulties of change can be initially effective as a motivational strategy that can lead to
a more secure therapeutic alliance. The empathic stance of the therapist inherent in EFT
can be particularly helpful in reducing the pervasive feeling of shame by communicating
acceptance. It is critical that clients feel safe in order to begin to explore their emotional
experiences. Safety in the relationship can be reinforced through therapists’ empathic
presence, unconditional positive regard, and congruence (Rogers, 1965); thereby com-
municating to clients that they are valued for who they are rather than for their
appearance.
Empathic reflections are often used to help establish and maintain the therapeutic
alliance and are “…therapist’s statements that attempt to distill the essence of what the
client is saying and to give the form to the unstated feelings or perceptions that lie
immediately below the surface of the client’s remarks” (Kennedy-Moore & Watson,
1999, p. 212). Empathic reflections facilitate the therapeutic alliance, help explore and
examine client’s beliefs and assumptions about themselves and the world, and facilitate
the client’s ability to regulate their affect (Watson, 2002). Empathic responses are gen-
erally delivered in a very gentle, prizing manner and help provide support during intense
exploratory work. Through this form of interpersonal soothing, clients can build a more
positive, less judgmental view of themselves (Barrett-Lennard, 1997; Bozarth, 1990;
Elliott et al., 2004). By accessing emotions through empathic responses, the therapist
helps clients process painful feelings, and symbolize and contain their emotions.
Clients with eating disorders often feel judged for their “incomprehensible” drive to be
thin and for engaging in physically harmful behaviors (e.g. purging or starvation) by friends,
family, and the public. Empathic understanding responses provide validation and support,
and can help clients feel that they are heard, thereby alleviating the burden of shame and
loneliness imposed by the secrecy of eating disorder (Elliott et al., 2004; Watson, 2002). In
the following example, the therapist provides an empathic understanding of the overwhelm-
ing sense of loss of control due to client’s feelings of loneliness and isolation:

Client: It’s so hard lto explain, when I am alone at home, it’s like, something takes
over and I start to eat everything I can get my hands on.
Therapist: It’s like somehow this feeling of loneliness overwhelms you, and you feel
compelled to eat. [empathic understanding]
Client: Yes, I can’t stand the loneliness. I just want to get rid of it. I guess bingeing
helps me.1

Empathic exploratory responses convey understanding and help clients who are particu-
larly disconnected from their emotional experiences gain a clearer understanding of it
(Elliott et al., 2004). These responses are presented in a tentative, curious manner to help
clients turn their attention inside so that clients can symbolize feelings not yet expressed
(Elliott et al., 2004; Kennedy-Moore & Watson, 1999). For example:

Client: I feel nothing. Just blank and disconnected.

Therapist: It feels kind of empty? … How do you experience the disconnection?
Client: I don’t know. I guess I feel kind of lonely and sad.

In this example, the therapist has reached a step further and helped the client connect her
disconnection with a poignant and more differentiated emotional experience of loneliness
 Person-Centered & Experiential Psychotherapies 285

and sadness. Exploratory responses can also facilitate emotional expression by tentatively
directing client’s attention to the bodily sensations, feelings and needs that have been
previously cut off during the binge and purge cycle or food deprivation (Watson, 2006).
Guiding questions can help clients to attend inward. Therapists may ask “What is
happening inside?” or “Where do you feel it in your body?”
The inability to label feelings is highly common among eating disorders, and can be
equally challenging for restrictors and binge-purgers. Empathic conjectures can be helpful
when clients have difficulties putting their experiences into words. For example:

Client: I wasted so much of my life worrying about my body, what to eat, when to
eat. My mind never stops, I am constantly thinking about food and how I
look. It feels like such a waste of time. I don’t want to keep living like this!
Therapist: You are tired of living with this constant pressure, and when you are aware
of it, you feel, what? Is there a sense of loss there?

This conjecture assisted the client to focus on an internal feeling to begin to differentiate
her experience that could lead to a potential exploration of grief and sadness of having
missed out on more fulfilling activities due to her eating disorder. Providing experiential
psychoeducation about emotions can further enhance client’s understanding of the rela-
tionship between their emotions and their eating disorder.

Psychoeducation
Psychoeducation around the complexity of emotions and the impossibility of “stopping”
feelings is helpful to discuss with this population. The therapist may communicate to a
client that the only way to stop feeling an emotion is to divert attention elsewhere, for
example, by engaging in bingeing. This can help the client to understand that while
avoiding emotions may seem like an acceptable short-term solution; this method does not
resolve the underlying problem (Corstorphine, 2006). Information on the functions of
emotion may be helpful in dissolving the negative perception of emotions as “bad.”
Educating clients about the key functions of emotions: for example that they help us to
communicate with others and influence others’ behavior (e.g crying to request comfort or
assistance); that emotions help prepare us for action (e.g. fear can get us ready to seek
safety); and that emotions provide us with information about our own needs (e.g. noticing
discomfort in the presence of someone may be a message that it is not in the person’s best
interest to socialize with them). To enhance the learning, the therapist can suggest
awareness homework where clients can observe and describe their emotions in a diary
(Corstorphine, 2006; Elliott et al., 2004), while reflecting on the physiological aspects of
emotion, what the emotion symbolizes, and what the associated needs of the emotion
might be.

Experiential focusing for an unclear feeling

Clients with eating disorders often view and treat their bodies with disdain. They
generally ignore their bodily felt sense as they find the focus on the body aversive and
frightening. As a result of this disconnect, they find their emotional experiences vague and
confusing. In EFT for eating disorders, it is important to encourage clients to attend to
their bodily sense and symbolize their experience in words or images (Elliott et al., 2004).
286 I. Ivanova and J. Watson

Below is an example of the therapist assisting the client to differentiate a sense of

numbness, which is common to those who rely on dietary restriction:

Therapist: What’s going on for you right now?

Client: I don’t know what’s going on? I’m kind of going blank.
Therapist: Could we stay with this “blankness” and just attend to it gently.
Client: OK.
Therapist: Where do you feel it?
Client: It’s in my chest.
Therapist: Can you describe it? Does it have a shape, colour, or a sensation there?
Client: Yes, it’s this…dark, grey cloud… and I feel pressure in my chest.

Here, rather than dismissing the “blank” feeling, the therapist has helped the client begin
to attend to it and explore it further. The next step would be to help the client to
symbolize it:

Therapist: As you attend to this dark, grey cloud that causes pressure in your chest, do
you get a sense of what it is about? Is there an image, or a feeling there?
Client: I’m scared. I am afraid I will never get better.

The client has shifted from an unclear, vague sense of numbness, and was able to
attend to and symbolize her inner felt sense of fear. Once her feelings are sufficiently
differentiated, the client can make sense of them and respond more appropriately to
situations. To further guide clients’ understanding of their overwhelming and confus-
ing emotional experiences, the therapist can suggest an empathic exploration of their
reaction.

Systematic evocative unfolding of a problematic reaction

Clients are often aware of the discrepancy between their beliefs of wanting to stop the
disordered eating behaviors and their continuing to engage in them. As a result, they
may be motivated to explore and understand what is underlying these problematic
behaviours or reactions. Systematic evocative unfolding is a highly appropriate inter-
vention to help unfold confusing emotional reactions. A problematic statement may
sound like:

Client: I don’t know why, but when my boyfriend went to bed, I snuck back into the
kitchen and ate way more than I should have. And I wasn’t even hungry! I felt
disgusting.

Once the client expressed her puzzling reaction, the therapist can guide the client to
vividly describe the scene or situation in which she experienced the feelings (Watson
& Greenberg, 1996), thereby facilitating the re-experience of the incident by exploring
the cycle that led to this reaction. This can further facilitate an exploration of the
meaning of the client’s reaction and enable them to be guided to that which the
emotion is alerting him or her. However, explorations of a puzzling reaction among
clients with ED can often be inhibited by the tendency to interrupt or block feelings
because emotions occur as threatening to them. Thus, it can be helpful to work
 Person-Centered & Experiential Psychotherapies 287

experientially to explore how they inhibit their emotional experiences via the two-
chair task.

Two-chair task for self-interrupting splits

The two-chair task can make explicit the ways in which clients block or shut down their
emotions. An example below demonstrates how a client with bulimia self-interrupted her
emotional experience:

Therapist: (the client was tearful, but smiling at the same time) As you are talking about
your parents leaving you all alone on your birthday and how painful that was
for you, there are tears…
Client: Yep, it was pretty bad.
Therapist: (gently) So it was really hard for you, and yet you have a smile on your face,
what’s that about?
Client: I guess it’s just me trying to diffuse the situation.

As with many clients with eating disorders, this client’s home environment was highly
dismissive of emotions. As a result, many of the clients fear that emotions will be too
painful to experience and so they learn to avoid them in order to cope. In this case, the
client smiling is an attempt to avoid being in touch with the pain associated with feelings
of abandonment. The therapist can invite the client to explore the characteristic ways of
responding to painful emotions.
Clients with eating disorders, particularly those who restrict, may state that they do not
feel any emotions (Dolhanty & Greenberg, 2007). In this case, it is important to work
through this with the client in order to avoid making them feel like they are failing at the
task of feeling something. Dolhanty and Greenberg (2007, pp. 107–108), demonstrated
how to work with this in the two-chair task:

Therapist: So what’s happening … it looks like you just shut down.

Client: Yeah – I feel nothing.
Therapist: Right, good … nothing is something. Is it like numb, or shut down, or kind
of neutral?
Client: Kind of numb.
Therapist: Aha…so it’s amazing … this ability to just turn off what you might be
feeling. I wonder if we can figure out how that happens. Come over here
(Switch.) Can you make her go numb?
Client: I don’t know. It just kind of happens. Like: “Don’t feel.”
Therapist: M-hm … Don’t feel because if you do …?
Client: If you do, it will hurt too much and you won’t be able to handle it.

This vignette demonstrates the client’s fear of emotional pain and together with the
therapist, she explores ways she shuts her feeling down to avoid the pain. By validating
the client’s experience of emptiness, the therapist is able to create a safe environment so
that the client can further explore habitual ways of responding to her emotions. Once the
client is able to symbolize their experience in words, they can interpret and differentiate
the feeling of “numbness” into a more functional view of their emotion (e.g. protecting
from experiencing pain), enabling them to regulate the emotion. The capacity to self-
regulate as a result of differentiating and labeling feelings may eventually replace the
288 I. Ivanova and J. Watson

dysfunctional eating behaviors as a way of managing emotions (Dolhanty, 2006). The

discrepancy clients experience between what they feel they “should” feel or do and what
they end up feeling or doing (i.e. engaging in disordered eating), can often result in a
conflict split.

Two-chair task for conflict splits

Working with a conflict or a self-critical split is particularly effective because it allows
therapists to experientially engage clients who are otherwise ambivalent about the
treatment by exploring the part that would like to feel better and the part that may feel
skeptical and scared of the change (Dolhanty & Greenberg, 2007). It evokes the berating
manner of the critic and makes the punitive voice explicit; this can often be softened
through the two-chair task. It can also help clients understand the role and function of
their critic (e.g. protecting the client from rejection and failure by encouraging isolation
and withdrawal), and can help transform the critic into a more integrated, effective
internal voice.
Clients with eating disorders put themselves down for being “fat” and being unable
to achieve their goal of being thin. Imagining the critical part of themselves that makes
them feel fat or disgusting in another chair makes the previously buried or hidden
critical aspect of the self alive and present. As a result, it becomes difficult to ignore
the punitive nature of the critical voice and the negative subjective experience that
result from it. Dolhanty and Greenberg (2007, p. 104) describe an example of a
conflict split with an anorexic client who explores how she becomes the agent of
self-shame:

Client: I’ll walk by a window and just think how fat I am.
Therapist: Come over here. (switch chairs.) Be the part that tells you you’re fat. Picture
yourself in the chair and tell her: “You’re fat.”
Client: You’re fat.
Therapist: What’s the tone when you hear it in your head?
Client: Oh, it’s nasty.
Therapist: Use it now… (with disgust) You’re fat.
Client: Yeah, you’re fat and disgusting and you make me sick.
Therapist: Come over here (Switch.) Tell her what it’s like to be talked to like that.
Client: It hurts.
Therapist: Yeah, it hurts. What do you need from her?
Client: I need her to stop.
Therapist: Can you tell her?
Client: (strengthened) I need you to stop always criticizing me.

In this instance, the client experiences feelings of shame by the critic, but through the
two-chair task is able to recognize her agency and identify the associated healthy
need. The two-chair task can be a powerful tool in further transforming maladaptive
emotions of shame, fear, and sadness of abandonment by activating the resilient
aspects of the client, and accessing self-compassion to transform shame; and soothing
and validation to transform fear and sadness. When clients are able to express the
impact of the self-critic on their well-being (e.g. shame, sadness, hopeless, etc.), and
understand its function (safeguard against failure, protection from abandonment, etc.),
and with the soothing presence of the therapist, they can begin to learn to negotiate
 Person-Centered & Experiential Psychotherapies 289

more adaptive ways of relating to themselves; thus, transforming the core maladaptive
emotions into healthy adaptive ones (e.g. maladaptive shame into compassion, fear of
abandonment into security). The goal in the two-chair task is to develop more self-
accepting, empowering, and integrated inner dialogues that render eating disorders
unnecessary.

Empty-chair task for unfinished business with a significant other

Due to invalidating environments, many clients who develop eating disorders did not
have the opportunity to express their emotions in healthy, adaptive ways, or to
differentiate from significant others (Haworth-Hoeppner, 2000; Watson, 2011).
Addressing a family member, such as their mother or father by imagining them in a
chair allows clients to express their unresolved feelings and enables them to create
new meaning from their experience (Dolhanty & Greenberg, 2007). In addition, this
process enables clients to develop a capacity to self-soothe and regulate emotions and
differentiate from significant others so that they can independently meet their needs
and develop new ways of being (Watson, 2011). Due to the highly evocative nature of
the empty-chair technique, even clients who are severely cut off from emotions are
likely to respond. The following example illustrates how a client responded during an
empty-chair exercise:

Client: I can’t understand how they could just leave me for my 16th birthday all
alone and go off to Europe. What kind of parents do that?!
Therapist: It sounds like this was very painful and you are angry with them. Tell them
how hurt you were. (gesturing toward the empty chair.)
Client: I am so angry you left me alone. You always left me alone. I was so lonely
and this just made me sicker.
Therapist: You feel so hurt, abandoned, remembering feeling so lonely. Tell them what
you needed from them.
Client: I needed you to not leave me alone. I needed you to be there and to show that
you loved me.

The empty-chair task enables clients to turn inward and attend to their own inner
experience and express it to the other. The empty-chair task can assist clients in accessing
the emotion of anger, for example, by becoming aware of the mistreatment and abuse by a
significant other, and assist them with establishing boundaries, such as assertive anger at
abuse, or disgust at maltreatment. In this way clients can develop healthy limits and
differentiate from the significant other (Watson, 2011). New elements are then integrated
into a more cohesive, differentiated sense of self in relation to the other.

Conclusion
Current literature highlights the importance of emotion in eating disorders. Deficits in
emotional processing among this population are well supported. Individuals with eating
disorders experience deficits in their ability to be aware, label, interpret, symbolize,
express and communicate their feelings and associated needs. Instead they numb their
feelings by starving, binge eat to push the emotions away or to self-soothe, and purge to
avoid or relieve themselves of the emotional discomfort. EFT for eating disorders can be
an effective treatment to address these emotional processing difficulties. EFT
290 I. Ivanova and J. Watson

interventions can assist clients to experience their emotions, make sense of them, symbo-
lize them in words, express them, help clients self-regulate, and transform maladaptive
emotions. An increased ability to regulate emotions can decrease the need for clients to
rely on problematic eating behaviours. New ways of looking at themselves and the world
allows them to respond in more adaptive ways to their environments.

Note
1. Unless otherwise indicated, transcript excerpts are a compilation of clients undergoing Emotion-
Focused Therapy for eating disorders with the first author.

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