The Role of Beliefs About Emotions in Emotion-Focused Therapy for Binge-Eating Disorder

Individuals with binge-eating disorder (BED) often experience emotion regulation deficits, including negative beliefs about emotions and low emotional expressivity. The current exploratory study examined whether emotion-focused therapy (EFT) for BED could change negative beliefs about emotions and emotional expressivity. Twenty participants were randomly allocated to either immediate treatment of 12 weekly one-hour sessions of EFT for BED, or a waitlist control group. Beliefs about emotions and emotional expressivity were assessed before and after 12 sessions of EFT or 12 weeks on the waitlist. A repeated measures ANOVA was used to examine beliefs about emotions and emotional expressivity changes. EFT for BED resulted in significant changes in particular beliefs about emotions (Overwhelming and uncontrollable, shameful and irrational, invalid and meaningless, and total score on the beliefs about emotions questionnaire) but not emotional expressivity treatment outcomes. This pilot study provides preliminary evidence that EFT may be effective in improving maladaptive beliefs about emotions in adults with BED. Trial registration ACTRN12620000563965, 14 May 2020, retrospectively registered.

Binge-eating disorder (BED) is the most prevalent of all eating disorders (Kornstein, 2017). Core symptoms include recurrent episodes of binge-eating while experiencing a sense of lack of control in the absence of compensatory strategies (American Psychiatric Association, 2013). In a recent meta-analysis, Hilbert et al. (2019) investigated the efficacy of psychological treatments for BED. They found that while psychological therapies, mostly CBT, demonstrated large effect sizes for the reduction of binge episodes n RCTs with inactive control groups, the abstinence rates post-therapy only ranged from 45 to 54%. There was limited evidence for using one treatment approach over another, and more extensive research focusing on mechanisms of change was recommended to further improve the effectiveness of psychotherapy for BED.
People with BED experience more intense emotions and more significant difficulties in emotion regulation than people without BED (Kenny et al., 2017), and the experience of negative emotions is amongst the best predictors for binge eating episodes (Svaldi et al., 2014). Therefore, psychological treatments with a more specific focus on the role of emotion and emotion regulation could be very effective in reducing BED symptoms. Preliminary evidence is emerging for the benefits of emotion-focused therapy (EFT) for BED. Glisenti et al. (2018) used a multiple baseline case series design in which individual EFT over 12 weeks was applied to six female adult participants with BED, with follow-ups at 2, 4-and 8-weeks posttreatment. All cases experienced reliable recovery from binge-eating psychopathology, a significant decrease in binge-eating frequency and a reliable recovery or improvement in overall emotion regulation. More recently, Glisenti et al. (2021) investigated the feasibility and efficacy of EFT for BED whereby participants were randomly allocated to an immediate EFT treatment or EFT waitlist control group. Participants receiving the immediate EFT demonstrated significantly greater improvement in binge episodes, the number of days on which binge episodes occurred, and binge-eating symptoms compared to participants in the EFT waitlist control group.
While outcomes related research is essential in establishing the feasibility and efficacy of EFT for BED, consideration also needs to be given to understand better how change occurs in treatment. A better understanding of the mechanisms of change may allow therapists to more efficiently target the variables that cause change, thereby improving treatment effectiveness or reducing the dosage of therapy required to be effective. Central mechanisms of change proposed for EFT include 1) a successful therapeutic relationship, in which the client feels empathically heard, understood, supported and safe (Elliott et al., 2004); and 2) identifying a primary maladaptive emotion that is obscured by secondary symptomatic emotions and then using an adaptive emotion to transform maladaptive emotion schemes (Greenberg, 2002).
Individuals with BED often experience deficits in emotion regulation (Leehr et al., 2015). Two facets of emotion regulation are emotional expressivity and beliefs about emotion. Emotional expressivity refers to the outward display of emotion irrespective of valence -positive or negative, or channel-facial, vocal, or gestural (Kring et al., 1994). Binge-eating and other disordered eating habits such as purging and dietary restriction have been linked to emotion regulation deficits in emotional expressivity (Perry & Hayaki, 2014). Further, emotional suppression (as opposed to expression) to manage negative and distressing emotions, including anxiety and sadness, has been found to increase the subjective intensity of negative emotions (Dryman & Heimberg, 2018). This indicates a relationship between emotional distress and emotional expressivity.
Beliefs about emotion are evaluated on continuums of attributes such as helpful or unhelpful, and controllable or uncontrollable (Ford & Gross, 2019). Negative beliefs about emotions are related to eating disordered pathology (Vann et al., 2013) and disordered eating (Strodl & Wylie, 2020). They may be formed during childhood (Manser et al., 2012), particularly in environments where communication about emotion has been ignored or responded to negatively (Ivanova & Watson, 2014). According to the metacognitive model of eating disorders proposed by Vann et al. (2013Vann et al. ( , 2014, metacognitive beliefs, such as negative beliefs about emotions, enact the use of maladaptive emotion regulation coping strategies, such as binge eating, when activated by either external triggers or distress.
The current pilot study aimed to gain preliminary evidence as to whether EFT for BED results in significant changes in beliefs about emotions and emotional expressivity. This investigation may guide the design of larger future interventional studies that can then further investigate the role of beliefs about emotions and emotional expressivity as mechanisms of change in psychotherapy for BED. It was hypothesised that participants receiving immediate treatment using EFT would experience significant decreases in negative beliefs about emotion and increases in emotional expressivity, from pre-therapy to post-therapy, compared with the waitlist control group.

Design
This exploratory analysis was based on a pilot randomised waitlist control trial findings. The sample size for the current study was calculated using the outcome measure of changes in binge-eating episodes from a series of case studies exploring the use of individual EFT to treat BED (See Glisenti et al., 2018). Participants were initially randomly allocated to either an immediate EFT treatment group (12 weekly EFT sessions) or an EFT waitlist control group (12-week clinical monitoring preceding 12 weekly EFT sessions) using a block randomisation method (Efird, 2011). This research was approved by the Queensland University of Technology (QUT) University Human Research Ethics Committee (UHREC) and met the requirements of the National Statement on Ethical Conduct in Human Research (2007). The UHREC Reference Number is 1700000986, and all participants provided written informed consent. Consolidated Standards of Reporting Trials (CONSORT) guidelines were fully adhered to-See Fig. 1.

Participants
The initial sample consisted of 21 participants, of whom 17 were female, and 4 were male. The average age was 44.52 (SD = 11.89) years, and the average age at first binge was 18.23 (SD = 8.07) years. Inclusion criteria included the following: being between 18 and 65 years of age, meeting the Diagnostic and Statistical Manual of Mental Disorders: DSM-V American Psychiatric Association-DSM-5 (American Psychiatric Association, 2013) diagnostic criteria for BED, and possessing sufficient English language skills to provide informed consent and participate in the study without translation. The exclusion criteria included current psychosis, intellectual disability, high suicide risk, drug or alcohol abuse, concurrent (i.e., prescribed medication), treatment for obesity, pregnancy and the presence of anorexia nervosa or bulimia nervosa.

Diagnostic Assessment
Pretherapy diagnostic assessment of BED was based on the Structured Clinical Interview for DSM-5-Research Version-SCID-5-RV (First et al., 2015).

Beliefs About Emotions
Beliefs about emotions were assessed using the Beliefs About Emotions Questionnaire-BAEQ (Manser et al., 2012). The BAEQ is a 43-item that measures six subscales relating to beliefs about emotions, including (1) Overwhelming and uncontrollable; (2) Shameful and irrational; (3) Invalid and meaningless; (4) Useless (5) Damaging and (6) Contagious. Respondents rate their level of agreement with each item on a 5-point Likert scale whereby 1 = strongly disagree to 5 = strongly agree. Example items are "When I feel upset, it means there is something to be upset about" and "I should feel ashamed about feeling upset". Higher scores indicate stronger 'negative' beliefs about emotions, and lower scores indicate more 'positive' beliefs about emotion, with a mean score derived for subscales to enable comparison between each. The six subscales have demonstrated adequate test-retest reliability and adequate to good internal consistency [0.69 to 0.88] (Manser et al., 2012). Within this study, good internal consistencies were demonstrated for the Total Score (α = 0.86), Overwhelming and Uncontrollable (α = 0.86) and Shameful and Irrational (α = 0.94), while adequate internal consistencies were found for the Invalid and Meaningless (α = 0.79), Useless (α = 0.72), Damaging (α = 0.70), and Contagious (α = 0.74) subscales.

Emotional Expressivity
Emotional expressivity was assessed using the Emotional Expressivity Scale-EES (Kring et al., 1994). The EES is a self-report measure of the extent to which individuals outwardly display emotions via facial expressions, vocalisations or gestures. Respondents are presented with a list of 17 statements and indicate how best each describes how they deal with emotions. Items are rated on a 6-point Likert scale where 1 = never true to 6 = always true. Example items are "I don't express my emotions to other people" and "I am able to cry in front of other people". The total score is calculated by taking the mean of these scores with higher means indicating greater levels of emotional expressivity. The EES has demonstrated high test-retest reliability (0.90) and good internal consistency (α = 0.91) (Kring et al., 1994). The internal consistency for this study was good (α = 0.87).

Procedures
Participants were initially telephone-screened for BED based on diagnostic criteria, according to DSM-5 (American Psychiatric Association, 2013). Twenty-eight participants were telephone-screened, of which five did not meet the diagnostic criteria for BED. Twenty-three participants meeting the diagnostic criteria for BED then completed the SCID-5-RV administered by the same research assistant with training in clinical psychology. All met the inclusion criteria. However, one participant chose not to participate due to the inability to commit fully to weekly treatment sessions, and one did not respond to contact attempts. Twenty-one participants were randomly allocated to either an immediate EFT intervention or 12-week EFT waitlist using a block randomisation method by a statistician independent of the research team. One participant dropped out of therapy due to family health reasons, leaving a final sample of 20 participants (10 completing the immediate treatment and 10 completing the waitlist control condition).
Participants allocated to the EFT intervention initially completed the BAEQ and the EES at pretherapy (Week 0) and post-therapy (after 12 weeks). Similarly, participants allocated to the waitlist control completed the BAEQ and the EES at baseline (Week 0) and then again 12 weeks later post waitlist period completion. The therapist was blind to participant data collection and entry.

Treatment
Treatment incorporated 12 weekly one-hour sessions of EFT for maladaptive emotions over 3 months. The treatment manual was initially adapted from Wnuk et al. (2015) by Glisenti et al. (2018) in a series of case studies exploring the use of individual EFT to treat BED. Phase 1 of the treatment focused on promoting awareness of emotions, welcoming and accepting emotions, putting emotions into words, and identifying primary emotions. Phase 2 focused on evaluating whether the primary emotion was adaptive or maladaptive, identifying destructive emotions, accessing other adaptive emotions and needs, and transforming maladaptive emotion schemes. Six main marker guided interventions were used in treatment in line with EFT protocol (Elliott et al., 2004;Greenberg, 2010). These were: (1) Empathic attunement and validation for vulnerability and establishing the therapeutic alliance, (2) Evocative unfolding for problematic reactions, (3) Experiential focusing for unclear feelings, (4) Two-chair work for self-critical splits, (5) Two-chair work for self-interruptive splits, and (6) Empty chair work for unfinished business.

Therapist
The therapist was the first author, a Clinical Psychologist with 25 years of practice experience who had undergone Level 1, 2 and 3 training in EFT at the York University Psychology Clinic with the primary developer of this approach, Distinguished Professor.
Emeritus, Leslie Greenberg. The therapist had approximately 4 years of EFT-specific practice experience before the study and was not involved in the initial treatment/waitlist randomisation process, data collection before or during the study, or data analysis until after the study. Supervision was provided by Distinguished Professor Emeritus, Leslie Greenberg, who was also a co-author of the original treatment manual used as a basis for therapy within the current study. Adherence to EFT protocol was reviewed-and rectified where necessary-during supervision based on video recordings of study treatment sessions.

Data Analysis
To test the hypothesis, a repeated measures ANOVA was used to compare the initial treatment group (n = 10) with the waitlist control group (n = 10) on changes in the dependent variables from baseline to week 12. Leven's Test was used to test the equality of error variances across all dependent variable groups, and Mauchly's Test of Sphericity was used to test whether or not the assumption of sphericity was met. Leven's Test and Mauchly's Test of Sphericity were nonsignificant for all analyses supporting the use of the repeated measures ANOVAs.

Therapy Retention
One participant (4.76%) dropped out after Week 4 of the EFT treatment for family health reasons. There was high adherence to EFT protocol, and the therapist made only minor and occasional rectifications based on supervision feedback. There was a high session attendance rate, and completing participants attended 100% of sessions.

Beliefs About Emotions (BAEQ)
The repeated measures ANOVA found significant reductions in the treatment scores compared with the waitlist control groups on BAEQ Total Score (F 1,18 = 26.17, p < 0.001), Shameful and Irrational (F 1,18 = 9.36, p = 0.007) and Invalid and Meaningless (F 1,18 = 19.98, p = < 0.001). The effect sizes for these differences are listed in Table 1. There was no significant difference between the two groups in changes from baseline to week 12 on beliefs that emotions are Useless (F 1,18 = 3.14, p = 0.09, η 2 p = 0.15) and Contagious (F 1,18 = 3.80, p = 0.07, η 2 p = 0.17), with a borderline non-significant difference on the Overwhelming and Uncontrollable subscale (F 1,18 = 4.38, p = 0.051, η 2 p = 0.20). While these differences between groups were not statistically significant, the effect sizes were all medium to large. Against expectations, we found an increase in the treatment scores on the Damaging subscale (F 1,18 = 8.39, p = 0.01, η 2 p = 0.32) compared to the waitlist control group.

Discussion
This exploratory study hypothesised that participation in EFT would significantly decrease negative beliefs about emotion and increase emotional expressivity treatment outcomes from pre to posttherapy. This hypothesis was partially supported. Participation in the EFT intervention resulted in significant improvements in BAEQ Total Score, and the subscales termed Shameful and Irrational, and Invalid and Meaningless compared with the waitlist control group. However, contrary to expectations, we also found an increase in beliefs that emotions are damaging compared with the control group. This unexpected finding requires further replication to understand if it is spurious or if EFT may strengthen beliefs that emotions are damaging. Given the paucity of research on the malleability of beliefs about emotions, there are few studies to compare our findings with. However, the findings are generally consistent with two other studies showing that psychotherapy can change beliefs that anxiety is malleable (De Castella et al., 2015;Reffi, et al., 2020). Our study extends this emerging line of research by identifying specific beliefs about emotion that may be modifiable by EFT and may contribute to changes in binge eating pathology. Contrary to our expectations, we did not find a significant increase in self reported emotional expressivity in the immediate intervention group compared with the waitlist control group, or over the course of therapy for the entire sample. This finding differs from another study that has shown that EFT increased emotional expressivity (Motaharinasab, et al., 2016), although this difference may be accounted for by methodological differences (e.g. differing length of treatment or differing measures of emotional expressivity).
The results of this study have several implications for future research. First, the findings of this study indicate that brief EFT for BED may lead to significant changes in beliefs about emotions but not emotional expressivity. In particular, this study gives confidence to researchers implementing larger interventions to measure changes in beliefs that emotions are shameful and irrational, and invalid and meaningless. Given that the changes in beliefs that emotions are overwhelming and uncontrollable only narrowly missed statistical significance, researchers should also examine changes in this belief in larger sampled intervention studies. Similarly, the finding that beliefs that emotions are damaging may increase due to EFT needs to be replicated to clarify if this was a spurious or real finding.
Future studies also need to include a larger sample size and more measurement points to allow multivariate analyses that can clarify the direction of causality and timing of these associations. One possibility may be to use an ecological momentary assessment (EMA) to examine in real time the relationship between changes in negative beliefs about emotions and changes in BED symptomatology during the course of psychotherapy. There is already metaanalytic evidence from EMAs that negative affect precedes binge eating (Haedt-Matt et al., 2011). Our study utilised the Beliefs About Emotions Questionnaire (Manser et al., 2012). While this questionnaire measures six beliefs about emotions, it is, of course, not a comprehensive measure of beliefs about emotions. Therefore, it would be helpful in future studies to assess other beliefs about emotions to identify the most important ones to target in interventions. For example, a questionnaire developed by Veilleux, et al. (2015) also measures beliefs that emotions can hijack selfcontrol, beliefs that emotion regulation is a worthwhile pursuit, and beliefs that emotions can constrain behaviour. Finally, the results of this study provide estimates of effect sizes of the association between changes in beliefs about emotions and changes in BED symptomatology that will be helpful to future studies in conducting power analyses to estimate sample sizes needed for larger intervention studies examining beliefs about emotions as a mechanism of change in psychotherapy for BED. If future larger intervention studies confirm that changes in beliefs about emotions may be an important mechanism of change in psychotherapy for BED, then this may guide the development of more targeted interventions for BED. Indeed, there is already preliminary evidence through a case series study, that Metacognitive Therapy may be effective in treating BED by challenging negative beliefs about cognitions (Robertson & Strodl, 2020). It would be relatively straightforward to apply Metacognitive Therapy to challenge specific negative beliefs about emotions to treat BED.
The current research has several limitations that need to be considered when interpreting the generalisability of the findings. First, the relatively small sample size meant that further research is required using larger samples with multiple time points, allowing for more sophisticated multivariate analyses such as hierarchical linear regression or cross-lagged panel analysis. In addition, another limitation is the gender bias, with the majority of the participants in this study being female. Further research with a larger sample of male participants is needed to understand whether gender is a moderator of the findings identified in this study. The outcome measures were also confined to self-report measures that limited participants' descriptions of attitudes and behaviours to those within their awareness. Finally, the current study was only 12 sessions, whereas research exploring EFT for eating disorders has typically involved more than 20 sessions (e.g., Brennan et al., 2015;Dolhanty & Greenberg, 2007;Ivanova & Watson, 2014;Robinson et al., 2013;Wnuk et al., 2015). As such, it would be important to examine whether the doseage of EFT impacts this study's findings.
In conclusion, this study provided initial evidence that changes in beliefs about emotions are modifiable due to EFT. These findings provide preliminary evidence to guide the design of larger future intervention studies that may further examine how changes in beliefs about emotions, and the timing of these changes within the course of psychotherapy, may be associated with changes in binge eating behaviours and other forms of psychopathology.