Focusing on Emotion: An Evidence Based Trans-Diagnostic Approach to Treating Eating Disorders.

Originally Published in NASW-NJ FOCUS, January 2022.

By Jackie Uveges, LSW & Nancy Graham, LCSW

“A transdiagnostic approach is ideal in the treatment of eating disorders as it can target not only the eating disorder symptoms, but also emotional dysregulation, intolerance, and experiential avoidance common with comorbidities such as depression, anxiety, and obsessive-compulsive disorder.”

Individuals who struggle with eating disorders often have difficulty expressing, processing, regulating, and tolerating strong or uncomfortable emotions and distressing experiences. The Renfrew Center’s Unified Treatment Model for Eating Disorders and Comorbidity (UT) 1 , a trans-diagnostic approach, allows patients to accept, manage, and communicate their feelings in a more adaptive manner without engaging in emotion avoidance.

Eating disorders are complicated and potentially devastating psychiatric illnesses caused by a complex combination of factors, including genetic, biochemical, psychological, cultural, and environmental. According to Wedig and Nock, “Eating and weight related concerns are defensive methods of directing attention to external problems and goals and to compensate for feelings of helplessness, insignificance, and vulnerability.” 2 The Renfrew Center’s evidenced-based Unified Treatment Model addresses not only an individual’s eating disorder, but other comorbidities through a careful integration of cognitive behavioral therapy, mindfulness, relational-cultural therapy, and exposure therapy.

A transdiagnostic approach is ideal in the treatment of eating disorders as it can target not only the eating disorder symptoms, but also emotional dysregulation, intolerance, and experiential avoidance common with comorbidities such as depression, anxiety, and obsessive-compulsive disorder. A transdiagnostic approach cuts across DSM-5 disorders, and targets core mechanisms, not specific disorders, while providing a unifying case conceptualization to the treatment of complex clients.

One hallmark of the UT is that it conceptualizes eating disorders as emotional disorders. The UT is an adaptation of an existing evidence-based treatment, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). 3 The Unified Protocol conceptualizes that individuals with emotional disorders experience negative affect more intensely and more frequently than the general population, view these emotional experiences as unwanted and intolerable, and use maladaptive emotion regulation strategies (attempts to avoid or dampen the intensity of uncomfortable emotion) to cope. The maladaptive strategies backfire and contribute to the maintenance of symptoms (ED symptoms, substance use, self-harm, etc.) and interpersonal disconnection.

Those with emotional disorders become experientially avoidant, meaning their drive to avoid negative emotional experiences may be evident in avoidance of situations, physical sensations, memories, and even emotions that make them feel badly. This experiential avoidance has been found to be a key maintaining factor for many psychiatric illnesses. What we have come to learn is that diverse symptoms function similarly and continue in a cyclical pattern. The individual experiences an unpleasant internal experience, which leads to emotional avoidance and unwillingness to have the emotion, resulting in avoidant and/or symptomatic behavior, and ultimately—albeit temporarily—relief from the unpleasant internal experience. Unfortunately, this results in long-term consequences for the individual, however the temporary relief that is experienced is often enough to keep the individual stuck in the cycle.

A patient, for example, may be avoiding stress at school or work by focusing on exercising excessively and rigidly controlling their food intake, as body size may be viewed as controllable, whereas stress at school or work may not. Recovery requires experiential challenge (doing things that have been habitually avoided) and reducing avoidance strategies, while also incorporating psychoeducation about the adaptive functions of all emotions, even those which can be uncomfortable, distressing, or may be perceived as being unsafe.

Some important considerations when discussing the treatment of eating disorders are the barriers for minority and/or low-income groups to accessing appropriate services, which are due to a variety of reasons. In one study of adolescents, researchers found that Hispanic participants were significantly more likely to suffer from bulimia nervosa than their non-Hispanic peers. These researchers also reported a trend towards a higher prevalence of binge eating disorder in all racial minority groups. 5 Additionally, Black teenagers are 50% more likely than white teenagers to exhibit bulimic behavior, such as binging and purging. 6 Despite similar prevalence rates of eating disorders among non-Hispanic White, Hispanic, Black, and Asian Americans, people of color are significantly less likely to receive eating disorder-related help and treatment. People of color with self-acknowledged eating and weight concerns had a lesser likelihood than white participants to have been asked by a doctor about eating disorder symptoms, despite similar rates of eating disorder symptoms across ethnic groups. 7 This is the same with mental health professionals, as clinician bias can also act as a barrier to accessing treatment.

Intersectional issues of class and weight stigma/fatphobia play roles in barriers to receiving a diagnosis and accessing various levels of care as well, which is especially true as treatment is often covered by private insurance and can be inaccessible for those with lower incomes, on Medicaid, or without insurance. Social workers can assist in addressing these disparities though expanding research and policy, providing education and resources to underserved communities, and increasing screening for eating disorders in all patients regardless of race, class, or size.

About the Authors:

Jackie Uveges, LSW

Jackie Uveges, LSW is a 2020 graduate from the Rutgers University School of Social Work. She is currently working as a primary therapist in the treatment of eating disorders at The Renfrew Center of Southern New Jersey.

Nancy Graham, LCSW

Nancy B. Graham, LCSW, is the Professional Relations Representative for The Renfrew Center of Northern New Jersey located in Paramus. She has many years of experience as a mental health professional and clinician both in New York City and New Jersey. She also has a private practice in Bergen County, NJ.