Single Case Study: Does EMDR Psychotherapy

Work on Emotional Eating?

Katrine Halvgaard
Copenhagen, Denmark

This article presents the methods and results of a single case study treating the effects of “emotional
eating” (EE). It provides a comprehensive review of the literature related to obesity and emotional eat-
ing; explains childhood experiences, which may contribute to its development; and describes how emo-
tional eating can become a default behavior for affect regulation. The background for the research is the
worldwide epidemic of overeating and obesity. The study was designed to examine whether treating the
symptoms of EE with selected protocols and methods within eye movement desensitization and repro-
cessing (EMDR) psychotherapy would have a positive effect, and the participant, a 55-year-old woman,
was treated with an adjusted version of the desensitization of triggers and urge reprocessing (DeTUR)
protocol, including resource installation, affect management, ego state work, and the standard EMDR
protocol. The treatment consisted of 6 weekly meetings, each lasting 1.5 hours, and 2 follow-up meetings
after 3 and 6 months. The measures, which were self-reported on a qualitative scale (0–10), included
the experienced feeling of control in general (affect regulation) in specific eating behavior before and
after the treatment, reduction of urge in triggering situations, number of situations with emotional eating
per week, and body image before and after the treatment. The participant experienced an overall positive
change in eating behavior, and the treatment could be one of the ways to reduce weight over time and to
ensure better results in stabilizing weight after weight loss.

Keywords: eating disorders (EDs); emotional eating; affect regulation; trauma; eye movement desensiti-
zation and reprocessing (EMDR)

O
besity has become a growing problem in de- or equal to 25 and obesity as a BMI greater than or
veloped countries, and according to the World equal to 30. The obesity epidemic is one of the most
Health Organization (WHO, 2015), overweight serious health problems facing the Western countries.
and obesity are linked to more deaths worldwide Despite a wide range of efforts, and a common un-
than underweight. According to the WHO, in 2014, derstanding that overweight is reduced by increase of
more than 1.9 billion adults aged 18 years and older physical activity and eating less, an increasing number
were overweight. Of these, more than 600 million of people are struggling with overweight and obesity,
were obese. In 2014, 39% of adults aged 18 years and and new approaches to prevention and treatment
older were overweight, and 13% were obese. In 2013, therefore need to be examined. This case study con-
42 million children younger than the age of 5 years siders how emotional factors contribute to the prob-
were overweight or obese. The incidence of obesity lem and whether eye movement desensitization and
nearly doubled between 1980 and 2008. Overweight reprocessing (EMDR) psychotherapy has a positive
and obesity are defined as abnormal or excessive fat ac- effect in treating emotional eating (EE).
cumulation that may impair health. Body mass index
(BMI) is a simple index of weight-for-height that is
Research Question
commonly used to classify overweight and obesity in
adults. It is defined as a person’s weight in kilograms Can you demonstrate positive effects of selected pro-
divided by the square of his height in meters (kg/m2). tocols and methods within the EMDR psychotherapy
The WHO defines overweight as a BMI greater than on emotional eating and as a result recommend this

188 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015

© 2015 EMDR International Association http://dx.doi.org/10.1891/1933-3196.9.4.188
approach in treating the emotional aspects of dis- physical perspectives (R. Shapiro, 2009). This case
turbed eating behavior and development of obesity? study considers how emotional factors contribute
to the problem and how the eating behavior is acti-
Literature Review vated not by physical hunger but by an experience
of a sudden hunger and craving for certain, typi-
Eating Disorders
cally high-fat and high-sugar “comfort”-food items
Eating disorders (EDs) are complex chronic illnesses (Campbell, 2011). The hunger is connected with up-
with physical, social, and psychological ramifications. setting emotions, and food is used as a primary source
The thread of obsessive concern with food, weight of comfort, coping, and emotional fulfillment, also
and appearance, inappropriate eating behavior, and called emotional eating.
body image distortions runs through anorexia nervosa
(AN), bulimia nervosa (BN), and binge eating disorder Emotional Processes and Obesity
(BED). The same thread runs through disordered eat-
In their article entitled “Emotions and Eating Behav-
ing—that is, problematic eating, where one eats “not
iour: Implications for the Current Obesity Epidemic,”
out of physical hunger, but to soothe, numb, comfort,
Levitan and Davis (2010) consider the role of emo-
or avoid” (R. Shapiro, 2009), which is called emotional
tions in eating behavior and in the current obesity
eating in this article. The National Institute for Health
epidemic, focusing on two phenomena: the stress-
and Care Excellence (NICE, 2004) states that individu-
related/emotional eating, which describes the use of
als who have EDs not otherwise specified should be
high-caloric, highly palatable foods to deal with nega-
treated in line with the treatment for the ED their
tive emotions, and overeating as a form of addiction.
symptoms most closely resemble. The ED most like
As a result of their review of several studies, they con-
EE is BED. Interestingly, the Diagnostic and Statistical
clude that there is substantial evidence that emotional
Manual of Mental Disorders (5th ed., DSM-5) does not
regulation plays a critical role in food consumption,
list EE among any of the criteria for EDs, taking into
and focus on emotional processes will be necessary
consideration the increasing scale and serious conse-
if significant progress is to be made in addressing the
quences of this phenomenon, as pointed out earlier.
obesity epidemic. They consider attachment theory,
which focuses on normal and abnormal emotional
Psychogenic Overweight
regulation, to be an important approach. Of particu-
According to Hart (2006), EDs can be divided into AN, lar concern, too, is the fact that high-caloric, highly
bulimia, and psychogenic overweight, also known as palatable foods, which are the most problematic in
comfort eating or emotional eating. Psychogenic over- terms of weight gain and obesity, also have the stron-
weight is here seen as a limbic disturbance, initiated gest effect on alleviating negative mood states in most
as a sort of self-soothing to meet emotional uneasi- contexts and therefore have a critical influence on the
ness that cannot be integrated into the mentalizing EE behavior. Stress and anxiety are also strong con-
functions of the prefrontal cortex. Instead, it will be tributors to EE, suggesting that multiple treatment
expressed on a limbic level, that is, through somati- approaches used in combination may be necessary for
zation. This dissociation results in an inner feeling of major progress to occur.
emptiness, and this diffuse emotionality is replaced
among other things by the consumption of food. The Avoidance of Feelings
physiological and psychological needs are temporarily,
Roth (1992) was among the first to link compulsive
although never entirely, satisfied. Eating gives a feeling
eating and perpetual dieting with deeply personal and
of satisfaction because it activates the same structures
spiritual issues that go far beyond food, weight, and
as if you had social contact. According to Hart, sugar
body image. She shows how dieting and compulsive
stimulates the release of opioids that again reduce
eating often become a substitute for intimacy. She
both psychical and psychological pain. Research shows
shows why many people overeat in an attempt to sat-
that mice, when separated from their mothers, cry
isfy their emotional hunger and why weight loss fre-
less from separation if they drink water with sugar.
quently just uncovers a new set of problems.
Maine (2000) addresses the issue and explains the
Emotional Eating
impact of a cultural and economic system that un-
The reasons for the development of obesity are com- dermines self-worth, self-acceptance, and self-control.
plex and caused by multiple factors such as neurobio- EE is often approached in terms of how to avoid or
logical, genetic, cultural, psychological, social, and get rid of the feelings. In the literature and in lifestyle

Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 189

Does EMDR Psychotherapy Work on Emotional Eating?
programs, people are often advised to engage in dis- 15–74 years—had experienced one or more trauma-
tracting activities, such as taking a walk or a bubble tizing life experiences, such as sexual abuse, mental
bath, as a way to avoid EE, without the understanding and physical abuse, violence, neglect, or the loss of a
of the self-regulatory function of the reach for food. close relative. According to the survey, 47.9% of the
Instead, the individual needs to develop the ability to group experienced one or more intrusive symptoms,
tolerate uncomfortable feelings and to regulate the in- which is one of the criteria for a diagnosis of posttrau-
tensity of feelings (Matz & Frankel, 2004). matic stress disorder (PTSD). Meanwhile, 80% of the
Albers (2009) introduces a collection of mind- group stated that they had felt helpless and that the
ful skills and practices that help individuals to cope traumatizing experiences had triggered the need for
with these difficult feelings. This concept of mindful comfort food and marked the day when food became
eating is probably helpful. However, mindful eating, a soothing strategy and the overweight had begun.
distraction, or avoiding feeling do not address deeper The study sees obesity as psychologically determined,
emotional or traumatic experiences from the past, often but not always with a traumatic etiology, and
which in this study is considered to be the new and consequently one of the recommendations for treat-
crucial approach for dealing with EE; this is essential ment in the study is trauma treatment.
in understanding the aim of this case study’s applica-
tion of EMDR to EE. Whether EE stems from early Traumatic Life Experiences and Obesity
traumatic material dysfunctionally stored in the mem-
These findings correspond to the Adverse Childhood
ory system in the brain, to be explained later, or from
Experiences (ACE) study (http://www.cdc.gov/
a bad habit and unfortunate choice of soothing strat-
violenceprevention/acestudy/), which is one of the
egy, the hypothesis is that treatment has to be focused
largest investigations ever conducted to assess associa-
both on the past history (trauma), present triggering
tions between childhood maltreatment and later-life
eating situations, and future affect regulation.
health and well-being. The study is a collaboration
between the Centers for Disease Control and Preven-
Affect Regulation
tion and Kaiser Permanente’s Health Appraisal Clinic
Disturbed eating patterns can in part be conceptualized in San Diego. More than 17,000 health maintenance
as an affect management problem with roots in early organization (HMO) members undergoing a com-
attachment relationships. The style of our early attach- prehensive physical examination chose to provide de-
ments to primary caregivers is crucial in determining tailed information about their childhood experience
personality development, and affect regulation develops of abuse, neglect, and family dysfunction.
out of these early attachment experiences (Ainsworth & The ACE study revealed that traumatic life experi-
Bell, 1970; Bowlby, 1969, 1973, 1980; R. Shapiro, 2009). ences during childhood and adolescence are far more
Strategies for affect regulation are encoded, un- common than expected and that the impact of the
conscious to unconscious, mother to infant, through trauma pervades the adult’s life, correlating with a wide
psychoneurobiological mechanisms for coping with range of problems, obesity being one of them (van der
stress. A secure, healthy attachment facilitated by emo- Kolk, 2014). According to van der Kolk (2014), trauma
tional attunement is critical to the development of produces actual physiological changes, including a re-
affect regulation, and for people with EDs, “. . . food calibration of the brain’s alarm system, an increase in
symbolizes the time when merger of mother with stress hormone activity, and alterations in the system
baby was or should have been a soothing experience” that filters relevant information from irrelevant infor-
(Scholom, 2009, p. 116). The binge eater and the person mation. Furthermore, trauma compromises the brain
suffering from EE lack an internal soothing presence area that communicates the physical, embodied feeling
to manage anxiety and turn to food, symbolic of the of being alive. These changes explain why traumatized
good mother. Affect regulation is expressed via the EE individuals become hypervigilant to threat and so of-
behavior, and defense mechanisms are forms of emo- ten keep repeating the same problems and have trouble
tional regulation strategies for avoiding, minimizing, learning from experience; this is not a result of moral
or converting affects that are too difficult to tolerate. failings or a sign of a lack of willpower or bad character
but is caused by actual changes in the brain.
Trauma
Treatment of Trauma
According to a Danish study by Elklit and Ilfeldt
(2005), more than 40% of a group of 286 obese According to van der Kolk (2014), one of the most im-
people—27 male and 259 female participants aged portant findings from treating trauma is the fact that

190 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015

Halvgaard
“remembering the trauma with all its associated af- of arousal engendered by distressing life events causes
fect, does not, as Breuer and Freud claimed back in them to be stored in memory in the limbic, nonverbal
1893, necessarily resolve it” (p. 194) and “research in part of the brain with the original emotions, physi-
contemporary exposure treatment, a staple of cog- cal sensations, and beliefs. When these dysfunction-
nitive behavioral therapy, has similarly disappoint- ally stored memories are triggered, this unprocessed
ing results” (p. 194). Fundamentally, there are three material often results in pathological or maladaptive
avenues of treatment to help reverse the damage, responses to what might be an ordinary event. The
according to van der Kolk: “1) top down, by talking, flashbacks and intrusive thoughts of PTSD are ex-
(re-)connecting with others, and allowing ourselves to amples of symptoms resulting from the triggering of
know and understand what is going on with us, while these memories. Besides severe symptoms of PTSD,
processing the memories of the trauma; 2) by taking named big T traumas, a wide range of life experiences
medicines that shut down inappropriate alarm reac- can be stored in a dysfunctional way, providing the
tion, or by utilizing other technologies that change basis for diverse symptoms that include negative affec-
the way the brain organizes information; and 3) bot- tive, somatic, and cognitive responses in the present,
tom up: by allowing the body to have experiences which will be referred to as small t traumas (Solomon
that deeply and viscerally contradict the helplessness, & Shapiro, 2008). The goal of EMDR psychotherapy
rage, or collapse that result from trauma” (p. 3). is to access and process these memories and targeted
One of the recommended approaches is EMDR experiences and transfer them from implicit and epi-
psychotherapy, which is a way to help people revisit sodic memory to explicit and semantic memory sys-
their traumatic past without becoming retraumatized tems. The originally experienced negative emotions,
and to allow effective memory processing and trauma physical sensations, and beliefs are desensitized as the
solution. According to van der Kolk (2014), “clinical targeted memory is integrated with more adaptive
practice has always been a hotbed for experimenta- information.
tion. Some experiments fail, some succeed, and some,
like EMDR, dialectical behavior therapy, and inter- Eight-Phase Treatment Approach
nal family systems therapy, go on to change the way
EMDR therapy is an eight-phase treatment approach
therapy is practiced” (p. 262). These findings and con-
(F. Shapiro, 2001) composed of standardized protocols
siderations are the basis for the focus and selection of
and procedures that facilitate a comprehensive evalu-
the method in this case study, which will be presented
ation of the clinical picture, client preparation, and
in the following section.
processing of past events that caused the pathology,
current disturbing situations, and future challenges.
EMDR Psychotherapy
One of the components used during the reprocessing
EMDR is recognized as a scientifically supported and phases is composed of dual attention stimuli in the
effective treatment for trauma that over the years has form of bilateral eye movements, taps, or tones.
been shown to be an efficient approach to address psy- The processing occurs in a systematic manner,
chological and physiological symptoms with remark- including (a) client history and treatment planning;
able results (F. Shapiro, 2014). EMDR was developed (b) preparation to include resourcing as needed;
by Dr. Francine Shapiro. The therapy was introduced (c) assessment of the EMDR target memory; (d) desensi-
in 1989 with the publication of a randomized con- tization using bilateral stimulation (BLS); (e) installation
trolled trial evaluating its effects with trauma victims of the positive cognition (PC); (f ) body scan; (g) closure
(F. Shapiro, 1989). Since then, substantial research has of incomplete sessions, and preparation for session to
been conducted, which supports the positive effect of end; and (h) reevaluation of the target at the subse-
EMDR therapy and documents that EMDR therapy quent session.
provides relief from various psychological and so- A justified hypothesis then is that EE and the even-
matic complaints (F. Shapiro, 2014; based on the adap- tual following obesity can be treated with an EMDR
tive information processing (AIP) model of Solomon approach focusing on past trauma history, the deeper
& Shapiro, 2008). current emotional triggers that activate the disturbed
eating behavior, and the future affect regulation.
The Adaptive Information Processing Model
Review of EMDR and the Treatment of EE
This model posits that the primary foundations of
mental health disorders are unprocessed memories of A growing body of literature indicates that EMDR can
earlier life experiences. It appears that the high level be useful in the treatment of a wide range of disorders

Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 191

Does EMDR Psychotherapy Work on Emotional Eating?
(F. Shapiro, 2014). However, the research literature is & Grand, 2009, p. 130). The limbic system—the emo-
relatively sparse in documenting the uses of EMDR tional control center—controls the hypothalamus, and
for clients with addictions, and even less information under stress, the limbic system sounds an alarm, which
is available to document the use of EMDR with be- stimulates the hypothalamus to release corticotrophin-
havioral addictions such as EE (O’Brien & Abel, 2011). releasing hormone (CRH). CRH stimulates the pitu-
However, EMDR psychotherapy and successful treat- itary gland to release adrenocorticotropic hormone
ment of different EDs is presented and discussed by R. (ACTH). In response, the sympathetic nervous system
Shapiro (2009). Scholom (2009) sees binge eating and releases norepinephrine and epinephrine, which in-
EE, in part, as an affect management problem with crease heart rate, respiration, and blood flow, to pre-
roots in early attachment relationships and describe pare for danger, igniting our fight-or-flight response.
how EMDR gets at the early nonverbal internal ob- The symptoms are often dissociation, impairment in
ject relations visually imprinted and stored in the right the ability of self-regulation and interactive regula-
hemisphere: “EMDR treatment of early negative ex- tion, little body awareness, little affect tolerance, and
periences fostering adaptive information processing a general chronic emotional dysfunction. The limbic
paired with emotional, empathic attunement within systems are activated and constantly alarming, mak-
the therapeutic relationship gives the ED person op- ing connections intolerable and hindering the capacity
portunities to reparent and rectify attachment prob- to learn new information. BED helps clients avoid dis-
lems” (p. 117). During treatment, special attention is tressing emotions, decreasing activation of schemata
paid to the attachment history, psychosocial develop- related to threats of safety, well-being, and self-esteem.
ment, trauma, and history of the emotional disorder. EMDR can, according to Cooke and Grand, counteract
Identification of resources and building of positive the effect of prolonged emotional stress by decreasing
networks are crucial for EMDR processing to forge activation of these perceived threats and thereby im-
new connections between the targeted dysfunctional prove neurobiological functioning. Treatment needs
memory network and those holding more adaptive to focus on stabilizing the limbic activation and teach-
information: “The focus is to foster the client’s ability ing the client to regulate the affect in the triggering sit-
to identify the feelings that they so tenaciously defend uations, and to develop self-regulatory abilities in the
against” (Scholom, 2009, p. 122). Furthermore, differ- activities of daily life. The treatment consists of three
ent affect management techniques, psychoeducation steps: stabilization, processing trauma, and reintegra-
in general, and a model for attuned eating are recom- tion. With a better regulation of the overactivated
mended in the treatment of binge eating and EE. limbic physiology caused by many interventions, and
with the affect management protocol (York & Leeds,
2001) being one of the methods, the client can begin
Neurobiological Perspective
to deal with underlying traumas, losses, or wounds
Cooke and Grand (2009) see EDs from a neurobiologi- that are activating the EE behavior, thereby increasing
cal perspective, which includes a basic understanding frontal lobe activity.
of appetite mechanisms and the effect of prolonged
stress. EDs are usually preceded by a stressful life event Ego States and Dissociation
or challenge that strains the individual’s coping re- R. Shapiro (2009) presents interesting work treating
sources, which again alters physiological and psycho- AN and BED and has discovered the need to work
logical systems. Through advances in neurobiology, a with ego states and dissociation in bringing about
more dynamic understanding of how stress impacts change with this difficult population. Ego states refer
ED symptoms is available. The hypothalamus controls to the fact that the personality is not
many important functions, including appetite and the
stress response, and is the main center for satiety and a fixed, monolithic entity. Rather it appears to be
thermogenesis. This center reads the genetically pre- made of parts or states, some of which mature
determined set point for normal body composition with the organism, others that become fixed or
and ensures that the body keeps in balance by effect- frozen in time at an earlier developmental stage.
ing appropriate feedback mechanisms such as appetite These arrested states typically form at the time
and thermogenesis. One hypothesis is that EDs stem of a traumatic experience. (p. 194)
not only from a missetting or misreading of the set- Dissociative strategies help the client to discon-
point reference but also from problems in the mal- nect from painful feelings, body sensations, and
functioning of the feedback corrective mechanisms: self-experience generated by trauma and, by doing so,
“This results in an overshooting in obesity” (Cooke to form a new ego state holding the pain. EDs seem

192 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015

Halvgaard
to mask underlying dissociative ego states that need to • Affect management skills, that is, the affect toler-
be integrated into the self. Within EMDR psychother- ance protocol (York & Leeds, 2001)
apy, these parts are conceptualized as dysfunctionally • Attachment history, psychosocial development,
stored experiences unavailable to the corrective and trauma and history of the emotional disorder, and
healing powers of the prefrontal cortex (F. Shapiro, identification of resources
2001). The purpose is to develop inner resources and • Ego state work
to integrate fragmented parts of the self and thereby • The standard EMDR protocol
get to know the different emotional parts that fuel Design. The case study included an EMDR ther-
the dysfunctional eating behavior. It might be diffi- apeutic treatment comprising an adjusted version
cult, especially when the state is so dissociated that of the DeTUR protocol and consisted of six weekly
it does not experience the bodily consequences of its meetings, each lasting 1.5 hours, and two follow-up
behavior. Ego state work is described by Watkins and meetings after 3 and 6 months.
Watkins (1998), Knipe (2012), and Schwartz (2001),
and useful EMDR protocols are presented by Forgash Participant. The client was a 55-year-old woman
(Luber et al., pp. 209–233). who has struggled with weight problems for most of
her adult life, with a BMI that has fluctuated between
23 and 29. She needs help to handle the emotional ele-
Case Study ment in her eating behavior and reduce the number of
Method situations during the day where she experiences loss
of control in relation to food. The client stated the fol-
In the literature, two different protocols are recom- lowing goal for her treatment: “I sometimes eat as a
mended for the treatment of addictions: the craving result of emotional arousal, and I eat when I actually
extinguished (CravEx) protocol, an EMDR approach don’t want to. I would like to increase my awareness in
to treat substance abuse and addiction developed by these specific situations and find ways to act differently,
M. Hase (Luber et al., 2010), and the desensitization to make other choices.” Notice that the client’s goal is
of triggers and urge reprocessing (DeTUR) protocol, not to lose weight, but to regain a better affect regu-
developed by Popky (Luber et al., 2010). However, lation and reduce the emotional arousal in triggering
neither of these protocols was explicitly designed to situations. The client contacted the clinic by herself.
treat EE. Based on a review of EMDR and the treat- Treatment. The following section presents the
ment of EE and a conversation with Dr. Michael Hase adjusted DeTUR protocol and the 10 phases of treat-
(workshop June 1 and 2, 2015, Copenhagen), the ment, with a summary of the essential approaches
DeTUR protocol was chosen as the one to apply in and considerations.
this case study. This protocol was developed to help Phase 1: History Intake and Evaluation of the Client.
clients reinforce positive coping by focusing on both High and low points in her life and her ED his-
treatment goals and relapse triggers. In the first part tory/trauma history were explored, as inspired by
of the DeTUR protocol, the client focuses on the posi- Hoffman and Luber (Luber, 2009, p. 5). It turned out
tive treatment goal. The client develops an image of that she had had a baby sister at the age of 7 years,
what life would be like when changes are made. After which significantly changed her role in the family.
enhancing this goal through the use of visual imagery She got less attention and was appraised by parents
reinforced by BLS, the treatment focuses on develop- and grandparents whenever she finished a plate of
ing both internal and external resources to support food and when she was kind and made no noise.
change. Finally, each of the situations in the client’s From her history intake, it became clear that the
life that trigger the unwanted behavior is treated. This client did not suffer from “big T” trauma, as men-
protocol, combining a future positive treatment goal tioned earlier (p. 6), but rather early life experiences
with systematic desensitization of triggers, has been that could be referred to as “small t” traumas. The
recommended by Dr. Michael Hase when the issue has client’s attachment style and core beliefs were eval-
more to do with a behavioral addiction (EE) than sub- uated to know more about the client’s strengths,
stance abuse, where focus is on the addiction memory. needs and deficits, and internal and external re-
The DeTUR protocol had to be adjusted with sources. Her parents were both tall and slim, and
some of the findings presented earlier in this article: they did not speak nicely about people being obese,
• Resource installation throughout the treatment so being slim was important in the family and one
• Focus on the initial stabilization phase before of the underlying beliefs. Her motivation to change
trauma treatment approach and eating behavior was rated high and

Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 193

Does EMDR Psychotherapy Work on Emotional Eating?
the treatment plan was introduced. The treatment The goal described how she sees herself coping and
plan was organized according to the following: functioning in the situations. The client chose an
image of herself on a beach, wearing her favorite
Present: the current situation and the relationship with
dress.
food today and treatment goal, focus on present
The next step was to let the client associate with
triggers
the goal—that is, to let the client experience how
Past: focusing on the trauma history when food be-
it would feel to successfully achieve the treatment
came the strategy to cope with emotions
goal, using associative representation to anchor the
Future: triggering situations and affect management
experience into the physiology. When holding the
Phase 2: Resource Installation and Development of a image, she felt “relieved, happy, calm, and feeling
Safe Place. The client was asked to think of different good.” Physical anchoring is a process of being able
situations in which she experiences herself as being in to replicate the physiological experience associated
control, mastering the situation, and using her com- with an emotion or state by linking it to a physical
petencies, and she was asked to define what specific experience such as a slight pressure on a part of the
personal resources made that possible. The resources body, for example, a knuckle of the little finger, sup-
that were most important to reach the treatment goal ported by BLS. This anchoring exercise is described
were defined, and finally, the client developed a safe in the DeTUR protocol but is a technique originally
place. The client’s resourceful thinking throughout presented within the system of neurolinguistic pro-
treatment was “I am serious about myself and my gramming (NLP; Dahl, 1993).
feelings, I am good enough,” and the core resources Anchoring—which in her case involved hold-
were “serenity and power,” leaving her with a bodily ing hands and putting pressure on the little finger
sensation of being calm and in contact with inner whenever she was in a triggering situation—proved
strength located in her heart. Resource installation to be very helpful to the client. It gave her a good
and safe place exercises were used throughout treat- feeling and was an exercise that could be done
ment and always at the beginning and at the end of discreetly.
each session. Phase 5: Identify Urge Triggers. In this phase, the
Phase 3: Ego State Work and Standard EMDR client made a list of situations, events, and stimuli
Protocol. The ego state that held the “disordered eat- that triggered the urge to eat in present situations.
ing behavior” according to the client’s trauma his- The idea was to help the client to understand that
tory, when food became the self-soothing strategy, the eating behavior was learned and to reduce the
was revealed and understood. It turned out to be negative affect that was connected with the early
“the 7-year-old girl, wearing a yellow dress, ready to trauma events. Even after past events and traumatic
leave for her dancing school’s end-of-season dance but experiences have been desensitized, present triggers
without any attention from the adults around her.” can still have a charge of their own. The triggers
The ego state work consisted of getting to know the represent those times when the client eats larger
sad and lonely 7-year-old girl, encouraging her to portions, the wrong types of food, unnecessary
collaborate with the adult state, and with the belief snacks, and so forth. The list of triggering situations
that “I am serious about myself and my feelings, I am was prioritized in the order of what seemed to be
good enough,” developed in Phase 2. The encounter important, from weakest to strongest. The client’s
between the 7-year-old state and the adult state was triggers were typically normal life situations, that
very emotional and a deep psychological experience is, late at night before bedtime and when arriving
and was evaluated by the client to be crucial for the home from work.
progress in treatment. Phase 6: Desensitize Triggers. Each triggering situ-
Other traumatic childhood experiences were treat- ation was desensitized through BLS, where the urge
ed with the standard EMDR protocol. to eat in the specific situation was the target. Trau-
Phase 4: Positive Treatment Goal and Associated matic material that might show up in the process was
Positive State. The client was asked to elaborate on treated with the standard EMDR protocol.
the treatment goal first defined in Phase 1 and de- Phase 7: Install the Positive State. In this phase,
scribe an image of how she would look being suc- because of the DeTUR protocol, the positive state
cessful and fully functional having attained her goal developed in Phase 4 is connected with the situa-
of better control in triggering eating situations. tion, event, or stimulus that triggers the urge to
The goal was stated in positive terms and was time eat. Whenever one of the triggering situations
related, so it could be achievable in the near future. occurs, the usual response is replaced with the

194 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015

Halvgaard
positive state that the client has anchored. The table 1. Urge Before and After Treatment
effect is that the new response begins to occur Urge Before Urge After
automatically. Triggering Situation Treatment Treatment
So, whenever the client experienced the urge to eat
in one of the described triggering situations, she used 16:00–17:00 pm when 9 2
the anchoring technique; held the positive treatment arriving home from work
goal and associated positive state, which was the im- Late night before bedtime 7 0
age of herself on the beach wearing her favorite dress At a restaurant, eating bread 8 1
and feeling “relieved, happy, calm, and feeling good,” Chips on a table 10 2
combined with the belief “I am serious about myself
Guests serving candy 3 1
and my feelings, I am good enough”; and applied pres-
sure to the anchor.
Each of the previous triggering situations was scale of 0–10, where 10 represents an experience
treated, with the client applying pressure to the an- of a very high urge to eat and 0 represents no urge
chor combined with BLS. Positive affect or thoughts (Table 1):
were reinforced by another set of BLS. When
negative responses occurred, more dysfunctional • Number of situations with EE per week
material could be addressed by the standard EMDR Before treatment 1–2 times per week, after treat-
protocol. ment less than once per week
Phase 8: Test and Future Check. The client was • Body image—satisfaction with own body before
asked to bring up the triggers, checking the level of and after the treatment
urge (LOU) to see if there was any remaining urge. Before treatment 8, after treatment 10, meaning
If not, the success was reinforced by BLS; if there very satisfied
was any remaining urge, the desensitizing phase was Interviewing the client about the experience after
repeated. treatment, the following were reported:
Phase 9: Closure and Self-Work. The process was How was the urge in triggering situations reduced?
evaluated. Throughout the treatment and at the end • “The feeling of urge was reduced using the tech-
of treatment, different affect management techniques niques that I was taught, especially holding the pos-
and exercises to overcome urges were introduced itive picture of myself being in control, registering
(R. Shapiro, 2009, pp. 125, 139). the positive feeling, combined with the pressure on
Phase 10: Follow-up Sessions. The follow-up sessions the knuckle of my little finger.”
were used to reinforce the gains the client had made;
target any new situation, event, or stimuli that had The client referred to Phase 4, “Positive treatment
been triggered between sessions; and teach new skills goal and associated positive state,” where the client was
if needed. asked to describe an image of how she would look being
successful and fully functional having attained her goal,
Measures. The effect of the treatment was mea- noticing the positive feeling, and, through associative
sured according to the following qualitative param- representation, anchoring the experience into the physi-
eters, based on the client’s self-reporting. ology by putting a slight pressure on her little finger.
Findings Applying EMDR in the Treatment of EE. The
effect of the treatment was measured according to the How do you explain the effect in general?
following qualitative parameters: • “It was helpful to look back on little Lise and the
• Experience of the feeling of control (affect regula- time when food became an issue. To understand
tion) in eating behavior before and after the treat- the little girl and how hard it was to have a sibling, a
ment (on a scale of 0–10, where 10 represents an baby sister, at the age of 7. The only way I could get
experience of a high feeling of control and 0 repre- attention was to be brave and eat up.”
sents no experience of control) Here, the client refers to the ego state work, where
The client reported that her experience of control we looked back at the time when food became a self-
in these specific situations was 3 before the treat- soothing strategy to reduce emotional uneasiness.
ment and 10 after the treatment. The purpose of this work was to integrate the dissoci-
• Eating triggers ated parts—the ego states holding the old traumatic
The situations that triggered the EE and the expe- material from the time when her relationship with her
rienced reduction of urge were self-reported on a mother changed as well as her role as an only child in

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Does EMDR Psychotherapy Work on Emotional Eating?
the family. The ego state work was combined with the to a larger population cannot be made. The client in
standard EMDR protocol. this study though could be a typical example of the
• “I have in general been more conscious of what many millions of people in the world struggling with
it is all about—the link between emotions, eating affect regulation and weight outside the psychiatric
behavior, old memories, and so on . . .” system. She is a hardworking woman with a so-called
This statement is because of the overall interven- normal lifestyle in a modern world with high stan-
tion and psychoeducational approach throughout dards and complexity. She functions well with good
the treatment. internal resources, is motivated to have a healthy life,
and had a safe upbringing, except for early life expe-
What was the most effective part of treatment? riences that could be referred to as small t traumas.
• “The combination of the techniques and getting to Her background history appears to be representative
know myself on a deeper level, to have my issues of many people in modern countries, which makes
out in the open.” the need for new approaches to prevention and treat-
• “The practice of a very simple and easy technique ment even more important. The treatment of EE is
that can be used anywhere and in all situations.” complex, among other things because each person is a
unique individual who deserves a personal assessment
Anything you missed during treatment?
and an individual treatment plan. There is no approach
• “Maybe more follow-up sessions.” that will work for all clients, and the future challenge
How was the effect after 3 months? is to adjust the treatment to the specific needs of the
individual and at the same time examine more general
• “After 3 months, I had to think about the techniques approaches to treating EE and other EDs.
to concentrate on holding my hands, putting pressure
on my little finger, taking a deep breath, and focusing Conclusion
on the positive image of myself as the little 7-year-old
girl dressed in a yellow dancing dress, and holding the The findings and the evaluation of the treatment by
image of myself as an adult, at the beach, wearing the client indicate that there is a positive effect on the
my favorite dress. Doing so, I felt warmth in my heart eating behavior and the affect regulation in the de-
and a deep calm feeling, and my urge disappeared.” fined triggering situations. This effect is also experi-
enced over time, at least after 3 and 6 months.
How was the effect after 6 months? The most effective part of the treatment seems to
• “I do not think that much about it. When I experience be the combination of the techniques of anchoring
the urge, which is seldom, I think, ‘Why now?’ Most the feeling into the physiology and working on a deep-
often, it is because I am tired, a bit frozen, or feeling er therapeutic level, offering an understanding of the
vulnerable in the situation. Then I hold my hands, underlying issues highlighted by the ego state work.
apply the pressure, and bring up the positive image.” The conclusion is that it is possible to demonstrate
a positive effect by applying EMDR, and more specifi-
Discussion cally, the adjusted DeTUR protocol, in the treatment
of EE. The treatment was helpful in this case, and
The hypothesis is that by applying the adjusted
given that the client is typical of the population of in-
DeTUR protocol, the limbic arousal and the need for
dividuals suffering from EE, it also seems reasonable
self-soothing through consumption of food are re-
to conclude that the development of obesity when
duced and replaced by a better affect regulation. The
driven by emotional avoidance could be reduced.
dissociated “ego state” holding the need for comfort
eating is then better integrated into the mentalizing
Further Research
functions of the prefrontal cortex, giving the client
the possibility for more conscious and thoughtful de- This single case study provides evidence for the ef-
cisions in triggering eating situations. The resulting re- fect of treating EE, but first of all, more research is
duced intake of sugar and other comfort or junk foods needed to clarify the effects of the adjusted DeTUR
again has a supposed positive impact on the complex protocol on a larger number of people suffering from
neurobiological functions regulating appetite and the EE. Research could also focus on other relevant proto-
main center for satiety and thermogenesis. This study cols, for example, the CravEx protocol, and combina-
shows that treating EE with EMDR psychotherapy can tions of these to examine possible effects. It would be
have a positive effect; however, the results stem from especially interesting to work more systematically to
treating one individual, and therefore generalizations see what EMDR interventions could be relevant when

196 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015

Halvgaard
focusing on the present situation, addressing the cur- Matz, J., & Frankel, E. (2004). Beyond a shadow of a diet: The
rent relationship with food and the present triggers; comprehensive guide to treating binge eating disorder, compul-
the past, focusing on the trauma history; and the sive eating and emotional overeating (2nd ed.). New York,
future, enhancing affect regulation and coping strat- NY: Routledge.
egies. In general, there is an urgent need for more National Institute for Health and Care Excellence. (2004).
Retrieved from https://www.nice.org.uk/
research to address the consequences of the obesity
O’Brien, J. M., & Abel, N. J. (2011). EMDR, addictions, and
epidemic as well as the increasing number of people the stages of change: A road map for intervention. Jour-
suffering from other serious EDs. nal of EMDR Practice & Research, 5(3), 121–130.
Roth, G. (1992). When food is love: Exploring the relationship
References between eating and intimacy. NY, Penguin.
Scholom, J. (2009). Integrating eating disorders treatment
Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, explo- into the early phases of the EMDR protocol. In R. Sha-
ration, and separation: Illustrated by the behavior of one- piro (Ed.), EMDR solutions II: For depression, eating disor-
year-olds in a strange situation. Child Development, 41:49–67. ders, performance, and more (pp. 114–128): New York, NY:
Albers, S. (2009). 50 Ways to soothe yourself without food. Norton.
Oakland, CA: New Harbinger. Schwartz, R. C. (2001). Introduction to the internal family sys-
Bowlby, J. (1969). Attachment and loss, Vol. I. Attachment. tems model. Oak Park, IL. Trailheads.
New York, NY: Basic Books. Shapiro, F. (1989 ). Efficacy of the eye movement desensiti-
Bowlby, J. (1973). Attachment and loss, Vol. II. Separation: Anx- zation procedure in the treatment of traumatic memo-
iety and anger. New York, NY: Basic Books. ries. Journal of Traumatic Stress, 2, 199–223.
Bowlby, J. (1980). Attachment and Loss, Vol. III. Loss: Sadness Shapiro, F. (2001). Eye movement desensitization and repro-
and depression. New York, NY: Basic Books. cessing (EMDR): Basic principles, protocols, and procedures.
Campbell, H. (2011). Managing emotional eating. Mental New York, NY: Guilford Press.
Health Practice, 15(8), 34–35. Shapiro, F. (2014). The role of eye movement desensitiza-
Cookie, L. J., & Grand, C. (2009). The neurobiology of tion and reprocessing (EMDR) therapy in medicine:
eating disorders treatment into the early phases of the Addressing the psychological and physical symptoms
EMDR protocol. In R. Shapiro (Ed.), EMDR solutions stemming from adverse life experiences. The Permanente
II: For depression, eating disorders, performance, and more Journal, 18, 71–77.
(pp. 129–150). New York, NY: Norton. Shapiro, R. (Ed.). (2009). EMDR solutions II: For depression, eat-
Dahl, O. V. (1993). Grundbog I NLP 1. Kommunikation og terapi ing disorders, performance, and more. New York, NY: Norton.
[Textbook l NLP 1., Copenhagen, Denmark: Paludans]. Shore, A. N. (2003). Affect regulation and the repair of self.
Copenhagen, Denmark: Paludans. New York, NY: Norton.
Elklit, A., & Ilfeldt, A. (2005). Der er et menneske indeni Solomon, R. M., & Shapiro, F. (2008). EMDR and the adap-
[There is a human being inside]. Psykolog Nyt, 18. Dansk tive information processing model: Potential mecha-
Psykologforening, Copenhagen. nisms of change. Journal of EMDR Practice and Research,
Hart, S. (2006). Betydningen af samhørighed, om neuroaffek- 2(4), 315–325.
tiv udviklingspsykologi [The meaning of cohesion, about van der Kolk, B. A. (2014). The body keeps the score: Brain,
neuroaffective developmental psychology]. Copenha- mind, and body in the healing of trauma. New York, NY:
gen, Denmark: Hans Reitzels. Penguin.
Knipe, J. (2012, October). EMDR toolbox: Using the EMDR Watkins, J. G., & Watkins, H. H. (1998). Ego states: Theory
AIP model for treating adults with complex PTSD. Paper pre- and therapy. New York, NY: Norton.
sented at the EMDRIA Conference, Washington, DC. World Health Organization. (2015). Obesity and overweight.
Levitan, D. R., & Davis, C. (2010). Emotions and eating be- Retrieved from http://www.who.int/mediacentre/
haviour: Implications for the current obesity epidemic. factsheets/fs311/en/
University of Toronto Quarterly, 79(2), 783–799. http:// York, C., & Leeds, A. (2001). Gate theory: An accelerated in-
dx.doi.org/10.1353/utq.2010.0226 formation processing model for developing functional state
Luber, M. (2009). Eye movement desensitization and reprocess- change. Paper presented at the Sixth EMDRIA Confer-
ing (EMDR): Scripted protocols: Basics and special situations. ence, Austin, TX.
New York, NY: Springer Publishing.
Luber, M. (2010). Eye movement desensitization and reprocess-
ing (EMDR): Scripted protocols: Special populations. New Correspondence regarding this article should be directed to
York, NY: Springer Publishing. Katrine Halvgaard, MSc Psychology, CBA, Specialist in Psy-
Maine, M. (2000). Body wars: Making peace with women’s chotraumatology, Accredited Practitioner in EMDR, Malm-
bodies. Carlsbad, CA: Gürze Books. mosevej 9A, 2840 Holte, Denmark. E-mail: [email protected]

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Does EMDR Psychotherapy Work on Emotional Eating?