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(p. 196) Emotion Regulation and Eating Disorders 

(p. 196) Emotion Regulation and Eating Disorders
(p. 196) Emotion Regulation and Eating Disorders

Julian Baudinet

, Lisa Dawson

, Sloane Madden

, and Phillipa Hay

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date: 21 March 2018

Eating disorders

Eating disorders in children and adolescents differ from those in adults in prevalence of clinical syndromes and in the psychopathology of disorders. Bulimia nervosa and binge eating disorder have a later age of onset than anorexia nervosa and Avoidant/Restrictive Food Intake Disorder (ARFID), which are the more common childhood problems. However, very little is known about ARFID and its treatment. Thus, this chapter will focus on anorexia nervosa and describe a new approach to emotion regulation in its management in adolescents. The diagnostic clinical features of common eating disorders (American Psychiatric Association, 2013) are listed in Box 10.1.

Anorexia nervosa occurs in around one in 400 adolescent girls. In pre-pubertal children eating disorders are less common and have a different sex distribution where almost a quarter of presentations manifest in boys (Madden, Morris, Zurynski, Kohn, & Elliot, 2009). ARFID is also common in children and boys; however, it is unclear if ARFID, or at least a proportion of ARFID cases of early onset, are a predecessor for anorexia nervosa or other eating disorders, or whether it is a distinct eating disorder with longitudinal studies needed to elucidate this. In children it often presents with significant weight loss in the context of somatic concerns such as nausea and fullness, and in adults with a specific anxiety related to eating.

In addition to differences in sex distribution, eating disorders of early onset also appear to have a greater responsivity to treatment and, in clinical samples, better long term outcomes than when onset presents in adulthood (Hay, 2015). A a strong body of research supports the efficacy of treatment in young people with eating disorders (See for example, Forsberg & Lock, 2015). The causes of eating disorders in children and adolescents are similar to those in adults; these include a family history of eating, mood and substance abuse disorders as well as obesity. Exposure to “anorexogenic” environments such as classical ballet and high levels of criticism and parental expectations are often associated with the onset and maintenance of disorders (Hay et al., 2014; Hay & Claudino, in press; Zipfel, Giel, Bulik, Hay, & Schmidt, 2015). The pathway into an eating disorder is a complex interplay of biological/genetic, psychological vulnerabilities and societal factors (Mitchison & Hay, 2014) and recent research has pointed to the importance of gene-environment interactions and the role of epigenetics (Campbell, Mill, Uher, & Schmidt, 2011).

Emotion regulation and eating disorders

Interest in emotion regulation and processing in anorexia nervosa has been long-standing. Difficulty in identifying and describing emotions has been noted in individuals since 1973 (Bruch, (p. 197) 1973). This construct, defined as alexithymia, has been consistently reported by clinicians and demonstrated by researchers with rates as high 77.1% in individuals with anorexia nervosa compared to 6.7% in healthy matched controls. In addition, rates of comorbid depression and anxiety in anorexia nervosa are high (Hatch, Madden et al. 2010).

Recent models of anorexia nervosa are increasingly emphasising the role of maladaptive emotion regulation strategies and difficulties with emotion identification as key precursors to the development and maintenance of anorexia nervosa (Haynos & Fruzzetti, 2011; Oldershaw, Lavendar, Sallis, Stahl, & Schmidt, 2015; Lavendar, et al., 2015). There is a small but growing body of evidence indicating that people suffering from anorexia nervosa show a greater use of maladaptive emotion regulation strategies, such as avoidance, emotion suppression, inhibition, repression, rumination and self-destructive behaviors (Haynos & Fruzzetti, 2011). Furthermore, people struggling with anorexia nervosa use fewer adaptive strategies compared to healthy controls (Haynos & (p. 198) Fruzzetti, 2011; Oldershaw, et al., 2015). This is important because less adaptive emotion regulation strategies are suggested to result in more overall emotional problems whilst contributing to psychological co-morbidity (Haynos & Fruzzetti, 2011)—a factor now recognized as a barrier to family based treatment (FBT) outcomes (Lock, Courtourier, Bryson, & Agras, 2006). Preliminary findings suggest emotion regulation difficulties may persist following weight restoration (Haynos, Roberto, Martinez, Attia, & Fruzzetti, 2014). Furthermore, they can moderate against treatment efficacy, contributing to the maintenance of anorexia nervosa (Racine & Wildes, 2015), with poor emotion regulation techniques related to relapse (Federici & Kaplan, 2008).

Evidence-based treatments

The first treatments developed for eating disorders were for anorexia nervosa. Early trials included adults as well as adolescents. The seminal study of psychological therapies were those of Russell, Szmukler, Dare, and Eisler (1987) and Eisler, Dare, Russell, Szmukler, le Grange, and Dodge (1997). This was a post weight-restoration outpatient psychotherapy trial where individual therapy was compared to family therapy. While there were no differences in outcomes between the two treatment arms, secondary analysis revealed better outcomes with family therapy in participants who had an eating disorder for less than three years and were under the age of 18. Although predominantly a trial of anorexia nervosa, this study also included participants with bulimia nervosa. Two further trials have looked at treatment interventions in study samples of adults and adolescents (Crisp, Norton, et al. 1991; Ball and Mitchell 2004), while there have been nine randomized controlled trials that have specifically studied the efficacy of psychological therapies for children and adolescents with anorexia nervosa which have included weight restoration in aims and outcomes.

There have been five randomized control trials of manualized family based therapies with a predominant behavioral focus, as in FBT. The first of these was by Robin et al., (1999). This was a small non-blind trial with unclear allocation concealment and thus, had a high risk of bias. Thirty-seven participants were randomized to either a families systems therapies or to an ego-orientated individual therapy. Those in the family therapy arm had significantly greater weight gain at the end of treatment and at a one-year follow up. Similarly, the second (Eisler et al. 2000; Eisler, Simic, Russell, & Dare, 2007) also had risk of bias in that there was unclear allocation, concealment and blinding. In this study, forty participants were randomized to either family based treatment, conjointly or individualized therapy where the parents were seen separately from the child with anorexia nervosa. Similarly in this study, there were no differences between the groups in outcomes at any point up to a five-year follow up with the exception that where there were maternal criticism participants showed significantly higher levels of improvement when therapy was separated.

Three trials that controlled for bias with adequate allocation concealment that involved independent or blind outcome assessments were conducted by Lock, Agras, Bryson and Kraemer (2005), Lock et al. (2010) and Agras et al. (2014). In Lock et al. (2005), 86 participants were randomized to either ten sessions over six months or 20 sessions over 12 months of FBT. Although there were no between group differences, the longer treatment led to greater improvements in people with higher levels of obsessive compulsive symptoms and those with non-intact families. Agras et al. (2014) compared FBT with systemic family therapy in 164 participants. There were no differences in weight or other primary outcomes. However, there was earlier weight regain and fewer hospitalizations in participants who were treated with family based treatment. On the other hand, systemic family therapy led to better outcomes with those who had higher levels of obsessive compulsive symptoms. Finally, Lock et al. (2010) randomized 121 participants to FBT (p. 199) or individual, adolescent focused controlled psychotherapy. This singular study reported higher remission rates and greater weight gain at both end of treatment and a one-year follow up in those randomized to family treatment.

Other studies done in the treatment of children and adolescents include research by Geist, Heinmaa, Stephens, Davis, and Katzman (2000) who randomized participants to family therapy where the families were seen for eight sessions with the patient, the patients parents and siblings or to a family group psycho-education arm where groups of families were seen in a workshop design for eight sessions. In this study of 25 participants, there were no significant differences between groups. This study also had risk of bias, as there was no blinding. Another study by Gowers et al. (2007) compared a specialist outpatient, manualized cognitive behavioral thearapy treatment intervention with separate parental counselling and non-manualized supportive and family care. This study found no differences between groups. Godart et al. (2006), in a high quality randomized control trial, compared a non-manualized psychodynamic systemic family therapy to usual specialist care in 60 adolescent participants. This trial reported significantly improved weight-gain and other outcomes in those who received the additional family therapy.

These trials of FBT have formed the basis for the leading evidence based therapy in children and adolescents with anorexia nervosa. It is notable that the majority was conducted with female participants and that only two found significant improvements in primary outcomes. It is also important to note that although there were minimal differences in symptomatic outcomes, family based treatment in the trial by Agras et al. (2014) was associated with lower financial costs and hospitalization rates. When compared with other non-family based treatments, FBT also demonstrated improved remission rates at follow-up (Courtourier, et al., 2010 Forsberg & Lock, 2015). It has to be acknowledged however, that although FBT and other family therapies have strong evidence for treatment of children and adolescents with anorexia nervosa (Zipfel et al., 2015) their efficacy for adolescents with bulimia nervosa is less established with mixed or inconsistent findings. In addition, there have been no trials in ARFID or binge eating disorder (Hay et al., 2014).

As previously highlighted, FBT has become established as the leading treatment for adolescents with anorexia nervosa. The treatment has been manualized (Lock & Le Grange, 2015) and disseminated internationally. The treatment includes three phases. Phase I focuses on empowering parents to manage all anorexia nervosa related behavior until the adolescent is weight restored. Following a period of weight maintenance, Phase II focuses on working with the adolescent to return to an appropriate level of control over food and eating. Phase III then focuses on life cycle events that may have been interrupted by the eating disorder.

Research indicates that FBT is effective for anywhere from approximately 30–60% of young people struggling with anorexia nervosa at the end of treatment, with these findings improved upon at follow-up (Forsberg & Lock, 2015). While this data is encouraging, particularly when compared to poor response rates to adult treatments (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007), it is now clear that FBT is not effective for a substantial minority of young people who continue to struggle or do not complete treatment. Furthermore, remission is often defined within the literature as reaching a specified weight range, which does not always correspond with full psychological recovery. Given a lack of effective alternative treatments, this leaves a substantial proportion of adolescents with anorexia nervosa at high risk of becoming chronically unwell.

Research is beginning to investigate possible factors associated with poor treatment responses or drop out in FBT. Initial findings have identified a range of family factors related to emotional expression and management that are associated with poorer outcomes or dropout. These include high expressed emotion, family conflict and criticism (Eisler, Simic, Russell & Dare, 2007; Lock, Coutourier, Bryson, & Agras, 2006; Russell, Szmukler, Dare, & Eisler; Le Grange, Eisler, Dare, (p. 200) & Russell, 1992), with parental warmth being related to good outcomes (Le Grange, Hoste, Lock, & Bryson, 2011). These findings are important, as Phase I of FBT can be very stressful and emotionally challenging for all family members as parents actively and consistently challenge the symptoms of anorexia nervosa. Accordingly, this often results in young people and families being faced with extremely distressing events on a regular basis with, potentially, reduced emotion regulation capacities. The treatment often requires this to be repeated consistently for many weeks to months.

Several individual factors have also been identified that are associated with poorer outcomes in FBT. Recent findings suggest that adolescents with more severe eating disorder psychopathology and those struggling with co-morbid Axis I and/or emerging Axis II psychological difficulties have a greater likelihood of dropout and may require a longer duration of treatment (Forsberg & Lock, 2015). This is important, as co-morbidity rates in anorexia nervosa remain high, with more than 50% experiencing a co-morbid anxiety disorder (Kaye, Bulik, Thornton, Barbarich, & Masters 2004) and between 50 and 70% and experiencing a major mood disorder (Godart, et al., 2006).

Emotion regulation and eating disorder treatments

The development of emotion regulation difficulties is hypothesized to be the result of numerous factors. These include biological factors, attachment and attunement difficulties within family systems (Zeman, Cassano, Perry-Parish, & Stegall, 2006), as well as traumatic childhood events (Dvir, Ford, Hill, & Frazier, 2014). Preliminary investigations are now being conducted into how best to include emotion regulation interventions into anorexia nervosa treatment. This has included the development of new treatments, such as the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA; Schmidt et al., 2012) and Emotion Acceptance Behavior Therapy (EABT; Wildes, Marcus, Cheng, McCabe, & Gaskill, 2014), as well as the modification or adaption of evidence based treatments from other areas of clinical psychology, such as Dialectical Behavior Therapy (DBT; Linehan, 1993). Research into the use of DBT for eating disorders in adults is promising, although yet to be rigorously researched and tested in adolescents (Bankoff, Karpel, Forbes, & Pantalone, 2012). Radically-Open DBT (RO-DBT) is a modified DBT treatment specifically designed to target emotion expression and the maladaptive strategy of emotional over control in anorexia nervosa (Lynch et al., 2013). The efficacy of RO-DBT has also yet to be tested in anorexia nervosa.

These emotion-focused interventions are being trialed in various modes of delivery ranging from individual and group, to family and multi-family interventions. Some examples include adding specific DBT informed emotion focused modules as an adjunct to FBT (Robertson, Alford, Wallis, & Miskovic-Wheatley, 2015), integrating emotion regulation ideas and techniques throughout FBT (Federici & Wisniewski, 2012; Robinson, Dolhanty, & Greenberg, 2015) or offering skills training group based interventions as one of a range of interventions provided in the context of a day program (Girz, Robinson, Foroughe, Jasper, & Boachie, 2013).

Emotion regulation difficulties have been identified as maintenance factors in anorexia nervosa and as a barrier to effective FBT. Given emotion regulation is influenced and impacted by environments and relationships (Oldershaw et al., 2015), it has been proposed that simultaneously addressing established interpersonal patterns may be an important part of treatment (Treasure & Schmidt, 2013; Oldershaw et al., 2015). Thus, taken together the literature suggests that while FBT is effective for the majority of adolescents, there are compelling arguments that adjunctive treatments targeting emotion regulation in the young person, as well as family members, may help in improving outcomes for those identified as at risk of poor treatment outcomes.

(p. 201) The Children’s Hospital at Westmead Treatment Program

The day program at The Children’s Hospital at Westmead operates five days per week. It is a program designed for adolescents and those who are not responding to outpatient FBT. The program offers three supported meals per day, adolescent group therapy each afternoon, weekly family therapy, individual therapy as needed, medical and psychiatric monitoring, a weekly parent group, multi-family groups, and educational support. The program is designed to provide increased intensity for adolescents and their families who are not responding to FBT by providing additional inputs to care. It is designed as an adjunct to FBT to facilitate its effectiveness, rather than a new treatment.

Accordingly, interventions for emotional regulation are not the sole focus of treatment, but are rather an essential component of a much larger treatment program. The aim of the program is to broadly address emotional regulation difficulties across a number of domains in the context of treating anorexia nervosa using FBT-informed systemic framework.

The program is designed to specifically address disturbances in the experience of emotions for children and adolescents with anorexia nervosa. The program is based on increasing emotional awareness and reducing emotional avoidance by supporting young people to develop adaptive emotional regulation strategies and the capacity to select how and when to implement these. Based on the dimensions of Gratz and Roemer’s (2004) multidimensional model of emotion regulation and dysregulation, the program specifically aims to help young people to:

  1. 1. Appropriately and flexibly managing distress

  2. 2. Maintain behavioral control in the face of distress

  3. 3. Increase emotional awareness, clarity, and acceptance

  4. 4. Explore willingness to tolerate difficult emotions in order to pursue a fulfilling life

A multidimensional approach to addressing these goals is used, including:

  1. 1. Specific skills-based groups (drawn from DBT, CBT, and ACT)

  2. 2. Experiential/behavioral opportunities to manage distress

  3. 3. Effectively utilising process and the structure of a day program (e.g., creating the right milieu for the group, engagement, validation, boundary setting, normalising, use of language)

  4. 4. Encouraging a life beyond anorexia nervosa /adolescent development

Appropriately and flexibly managing distress

Patients are taught a variety of specific techniques to modulate the duration and intensity of their emotional responses. Mindfulness is a key intervention in emotion regulation, with young people introduced to mindfulness at the commencement of their treatment and practiced daily at the beginning of all therapeutic groups. Mindfulness practice includes mindful breathing, mindfulness of objects, music, and mindful games. How mindfulness can be an effective tool for managing distress is discussed and the ways it can be employed is problem solved by staff and patients. It is particularly encouraged after more challenging meals as a way to be in the present moment, non-judgementally, and not to dwell on the meal that has just past or is upcoming.

Participants are also taught other ways to manage distress including distraction, self-soothing, using intense sensations, and radical acceptance. Young people create their own “self-soothing kits” by collecting objects that can be accessed in the moment of distress or remind them of strategies to use. Using such multiple emotion regulation methods flexibly (not relying on only one method) is encouraged, with patients assisted to match challenging situations with appropriate emotion regulation strategies.

(p. 202) Central to this, is teaching young people how to identify the early signs of their distress and the importance of intervening early in distress management. Creating “distress thermometers,” where participants map the physical, psychological and emotional changes that occur as their distress increases from zero out of ten (no distress) to ten out of ten (high distress), is part of this. Following this, young people then match strategies with differing levels of distress intensity. As distress becomes exponentially harder to manage the more it intensifies, staff focus on and support young people to intervene early in their distress management. Young people are encouraged to involve family and other support as needed.

Additionally, patients’ beliefs about their capacity to effectively manage emotions are challenged. Many young people in the program have strong beliefs that they do not possess adequate skills to effectively and adaptively modulate emotional experiences—a common experience in anorexia nervosa (Lavender, et al., 2015). Situations where young people effectively manage distress are identified and amplified by staff with young people supported to identify and label their own skills to help increase self-efficacy.

Maintaining behavioral control

The ability to maintain behavioral control in the context of heightened negative emotional arousal is an important component of emotional regulation. While within-session experiential emotional arousal has been argued as essential for addressing emotional dysregualtion (Greenberg & Pavio, 1997), creating such experiences in outpatient treatment is generally challenging, not least because those with anorexia nervosa are often highly emotionally avoidant, scared of emotion, and lack motivation to change (Hoetzel, von Brachel, Schlossmacher, & Vocks, 2013). In traditional FBT the meal session is a good opportunity for this, however, such a session generally occurs just once in treatment. The meal session is also often based around a food challenge and offers a lot of coaching by the therapist for parents, but less for the young person.

The three meals per day provided in the day program provide patients with extensive practice at experiential emotional arousal in a therapeutic context. Meals are utilized not only as a means of providing young people with anorexia nervosa with sufficient energy requirements, but also as an opportunity to provide young people with repeated exposure to distressing events and a means to practice and utilize emotion regulation skills learned in the program. This is done explicitly by reminding and encouraging young people to use specific emotion regulation in response to food and challenging eating disorder rules or behaviors during meals, and implicitly by establishing an environment that aims to be less clinical than traditional inpatient settings. While clear boundaries remain, humour and engagement is utilized to create an adolescent-appropriate environment. For example, meal times always include music, conversation, jokes, or games with all young people being equally engaged.

While all eating disorder inpatient treatments provide meals, there are benefits to providing this in combination with a complementary psychological treatment (for those who are well enough to no longer require inpatient care). This is supported by Oldershaw and colleagues (2015), who suggest that interventions for people with anorexia nervosa should include and seek a balance between behavioral or experiential components and cognitive components. The meals provide opportunities to help young people manage their distress in vivo by drawing on psycho-education and distress tolerance skills. During meals, the young people must inhibit dysfunctional behaviors when distressed, such as refusing to eat, absconding, eating slowly, or hiding food. If someone does become distressed they are encouraged to draw upon skills they have learnt and other young people are invited to also encourage the young person struggling and provide advice.

(p. 203) Beyond food and eating, behavioral/experiential opportunities to manage distress are also encouraged, planned for and debriefed. Young people are encouraged to practice managing many distressing situations, particularly those related to adolescent development e.g., turning to parents when distressed (practicing openness) and attending social events that might be anxiety-provoking. Young people are also encouraged to tolerate changes to their body occurring with weight gain.

Emotional awareness, clarity, and acceptance

Many young people with anorexia nervosa are inattentive to their own emotional experiences and struggle to understand their emotions and the ability to differentiate between affective states. They also often have difficulty accepting emotions and often reject emotional experiences. Accordingly, therapeutic groups that specifically target understanding and accepting your feelings are an essential component of the program.

Groups to support this focus on identifying and labelling emotions, differentiating between the intensity of different emotions, exploring primary and secondary emotions, investigating the function of emotions, the pros and cons of having feelings, and challenging myths about emotions are utilized. Young people have opportunities to practice recognising their own emotions as well as those of others.

Outside of specific skills-based groups, participants are encouraged regularly to identify, label, and reflect on their emotional experiences. Each morning young people are asked about the previous night and asked to describe how they felt, label the feeling, rate the intensity of the feeling, identify how it affected them, how the feeling was managed and how they would like to manage it next time. Experiencing emotions, including distress, is normalized. Staff model healthy emotional regulation by helping young people label their emotions as well as normalising and validating the young person’s emotional responses (e.g., “I can understand why you felt that,” “when I have that feeling it also feels pretty bad”).

Psycho-education about the impact of suppressing and avoiding emotions is provided. This includes the functional aspects of using starvation to avoid experiencing difficult emotions and the long-term consequences of this and how rejecting emotional experiences can result in secondary negative affective states regarding the primary emotional response.

Willingness to experience emotional distress

Throughout the program, normal adolescent development is encouraged, as staff actively support young people to value and remain on their normal adolescent developmental trajectory. For example, conversations are had about gaining independence from parents, learning to drive, attending school dances and what life after high school may look like. Staff emphasize the importance of being willing and able to tolerate aversive emotional experiences in the context of pursuing activities that are meaningful to the individual. Young people are encouraged to explore what it will mean to them now and in their future lives if they do not pursue recovery by avoiding emotional distress and contrast this with the impact of pursuing meaningful life activities (e.g., school, study, careers, sport, friendships and relationships). Activities are linked to specific eating disorder symptoms, for example, what will it mean for young people if they are unable to eat in front of or with others. Activities include exploring the pros and cons of having an eating disorder, living a valued life and completing pie charts for now and the future without anorexia nervosa.

(p. 204) Case example

The case of Emma outlined below is a combination of several patients and their families who have completed the day program. The case is used for two purposes; firstly, to give an example of the way emotion regulation interventions can enhance standard family based treatments and secondly, to illustrate the importance of not only providing young people with a forum to learn skills, but also highlighting the importance of ensuring there are the appropriate structures and therapeutic processes working in tandem to facilitate skill implementation.


Emma first presented with anorexia nervosa when she was 16-years-old. She weighed 41kg, was 156 cm tall and presented with medical complications of her weight loss including bradycardia (low heart rate) and hypothermia (low temperature). She resided with her mother, Leanne. Her father had been living in a separate house since the acrimonious breakdown of her parents’ marriage 18 months prior her 19 year-old brother had moved out of the family home at the completion of high school. Emma had an eight-month history of food restriction and compulsive exercise resulting in a 7kg weight loss. She reported a six-month history of amenorrhea.

Emma described experiencing significant mood difficulties for the previous nine to twelve months, with reduced sleep, increased social isolation and anhedonia. Emma had been engaging in deliberate self-harm of superficial cutting on her wrists and hip up to twice a week for the previous three months. She described passive suicidal ideation, denying any active plans or will to commit suicide. Her presentation occurred in the context of ongoing, severe bullying at school and her grandmother passing away nine months prior with bowel cancer. Emma also described experiencing separation anxiety from her mother, Leanne, up until early primary school.

Emma was admitted to an inpatient paediatric ward for medical stabilisation and psychological containment. Following her discharge FBT was provided by a clinical psychologist. After nine months of treatment Emma’s weight had slowly been reducing and family conflict continued to escalate. This had resulted in several occurrences of Emma running away from home during meals and physically intimidating her parents by threatening to hit them and on two occasions assaulting them.

At this point the day program was offered to Emma and her family to contain Emma’s weight loss, stop the escalation of dangerous behavior, provide skills training to Emma around emotion regulation and increase systemic empathy and understanding. The aim of the admission to day program was to break the vicious cycle of Emma’s experience of parental invalidation resulting in Emma’s emotional distress and behavioral escalation.

Over the course of her admission in the day program, emotion regulation and distress tolerance were key treatment interventions for Emma. Emma’s goal was to find ways of not becoming so angry that she needed to run away during meals or become threatening to her mother; something that made her feel very guilty. The daily adolescent group provided the most direct method of equipping Emma with the specific knowledge and skills around how to regulate her emotions. Box 10.2 outlines the selected skills Emma was taught in the group. Emma initially struggled with participating in group, often saying very little or saying she had tried everything and it did not help. While this was challenging to staff initially, through validation, encouragement and genuine interest in her difficulties staff were able to engage Emma in the process of group discussions, even though content remained difficult to engage with.

In tandem with skills group, the day program context provided an opportunity for staff to prompt the early identification of signs of distress, the communication of difficult emotions and the appropriate use of skills in different contexts throughout the day, such as during difficult meals (p. 205) or following stressful events. By ensuring group sessions involved practical elements, in vivo tasks or experiments and homework tasks, the environment ensured Emma experimented with skills, albeit begrudgingly. This slowly allowed her to experience some mild benefits from skill implementation, which then allowed her to generalize them from their use on the program to life outside of the program. Staff consistency in their relationship with Emma facilitated a safe space for her to feel accepted, despite frequent emotional outbursts. This allowed her to feel more comfortable in trying new things and reduced feeling of shame or embarrassment.

Importantly, other therapeutic aspects of the program, which were not directly related to emotion regulation skill development, were seen as key to helping Emma improve her ability to regulate her emotions. Family and multi-family sessions provided an opportunity for Emma to involve Leanne in emotion regulation skill development and planning could be done with the therapist (p. 206) as to how Leanne could best support Emma with skill use. Additionally, with Leanne spending less time providing meals for Emma, this enabled her to plan more specifically around the meals she was supervising. This allowed her to feel more prepared and confident, leaving her more able to tune into Emma’s needs, reduce criticism and provide much needed validation during the meals. Similarly, multi-family groups and meals were also beneficial for Emma as they provided repeated opportunity for staff to model and coach Leanne on how to support Emma with consistent warmth and firmness, as well as skill use and implementation.

Effective skill implementation only really began to result in noticeable changes for Emma four to five weeks after she commenced treatment. Through the process of staff using a firm but kind approach, with consistent boundaries and communication across all activities, Emma settled enough to attempt learnt techniques. She described finding it helpful being “checked-in” with frequently and said it provided the opportunity to test out expressing her more difficult emotions. She also said the experience of interacting with staff in multiple therapeutic context (e.g. meals, groups, family therapy) was beneficial. She said this exposure to staff across settings, as well as staff being able to engage in adolescent appropriate conversations, use humour, model appropriate eating, and tolerate high affect allowed Emma to feel able to accept and engage in the program. It was then through this connection that Emma described feeling able to experiment with alternate ways of managing her emotions and tolerating feelings of worthlessness and hopelessness.

Emma was discharged from the day program after completing 11 weeks. She was discharged within her healthy weight range after having gained four kilograms. While she continued to feel distressed around meals and many eating disorder behaviors persisted, she and her family said they felt much better equipped to continue to make gains in outpatient treatment. Both Emma and Leanne said that it was the combination of Emma learning new ways to regulate her emotions with Leanne being able to validate, understand and provide support around skill use that made them feel less stuck and able to move forward in treatment.


A growing body of literature indicates FBT is an effective treatment for adolescents with anorexia nervosa. Nevertheless, FBT is not effective for everyone, with a significant minority continuing to respond poorly to even the best available treatments. Given the role emotion regulation difficulties are hypothesized to play in the development and maintenance of anorexia nervosa, modifications to FBT that target emotion dysregulation are emerging. The case of Emma highlights a few key factors to consider when designing and implementing emotion regulation focused adjuncts or modifications to treatment. It highlights the importance of matching skills training with a consistent program structure and a positive group milieu. It is through the combination of these three factors that progress in treatment is hypothesized to occur. In the case of Emma, without the structure or milieu, skills training was unlikely to have been meaningfully attempted potentially adding to her feelings of hopelessness and helplessness. It was through the combination of all three elements that psychoeducation was delivered in a format and environment that allowed Emma to make meaningful treatment gains.

This approach to improving emotional regulation in adolescents with anorexia nervosa is in the early stages of assessment and further investigation and controlled trials are needed. Further research is also indicated to investigate the best approach to young people with other eating disorders including bulimia nervosa and binge eating disorder where individuals may have concomitant problems with impulsivity and emotion regulation. There is a small body of research supporting the efficacy of a modified individual outpatient form of dialectical behavior therapy in adults with bulimia nervosa or binge eating disorder (Safer, Telch & Agras 2001; Safer (p. 207) Robinson, & Jo, 2010) and trials are now being run in adolescents. Although research is promising, it is in the early stages and further investigation is required involving large-scale unbiased studies. However, it is important to note, treatment outcomes have high success rates (20–60%) when eating disorders are treated in childhood and adolescence; which is imperative, as adult anorexia nervosa is one of the most challenging psychiatric illnesses to treat effectively with one of the highest morbidity rates.


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