Incorporating Meta-Emotions in Integrative Cognitive-Affective Therapy to Treat Comorbid Bulimia Nervosa and Substance Use Disorders in a Latina American

1 Theoretical and Research Basis for Treatment

2 Case Introduction

N ¹ was a 35-year-old immigrant Latina American who was 5 feet 8 inches tall. She sought IOP treatment for disordered eating patterns and feelings of depression and worthlessness. Prior to this, N was receiving weekly psychodynamic-informed supportive therapy and medication management from a psychiatrist to manage eating, alcohol and cocaine use disorders, and emotional instability. N was referred to IOP by this psychiatrist following an increase in disordered eating behaviors and emotional lability. N weighed 178.5 pounds when she presented for IOP’s initial assessment.

3 Presenting Complaints

N’s chief complaints surrounded her nightly binge eating episodes, where she mechanically looked for foods in her kitchen cabinets and ate until she felt “stuffed.” She reported feeling out of control and out of touch with her surroundings during these 10-min episodes when she would consume over 3,000 calories. She purged approximately once a week and reported excessive thoughts about food and her body image. N engaged in excessive, driven exercises ² (e.g., riding the bicycle for over 1 hr each day, working out at the gym for 1 to 2 hr for 3 or more times per week) with the intent of compensating for weight gain due to her binge eating. Consistent with other symptoms associated with bulimia nervosa, N reported feeling guilty and anxious if she did not engage in these exercise activities and feeling relieved to engage in binge eating if she had exercised on a given day. In addition, she reported daily mood swings: feeling depressed, worthless, irritable, frustrated, and having frequent crying spells and shortness of breath. She complained about “spending sprees,” such as splurging US$100 on food but not having enough money to pay for other bills. She had been sober from cocaine for 5 months, and denied any current problematic drinking. Per self-report, N had 2-3 standard alcoholic beverages ³ for about 5 times each week, and engaged in at least one binge drinking episode (i.e., she consumed more than 15 drinks) per week.

4 History

N was born and raised in a Latin American country and moved to the United States for college. She was married but separated from her spouse at the time of admission, and finalized her divorce in the first month of treatment. N described her marriage as unhealthy because her spouse regularly engaged in substance abuse with her. She lived with a roommate in an apartment and worked as a customer service clerk at a telecommunication company. N reported that she was on extended medical leaves when she sought residential treatment and partial hospitalization (PHP) previously but was working full-time during the present IOP treatment. In addition to regular social contact with her roommate, N reported that she maintained a close and supportive relationship with her younger sister. Besides her sister, N’s other family members all resided in her country of origin. N had regular phone contact with her parents and brother but stated that she maintained a “love–hate relationship” with her mother due to her mother’s frequent criticism of her appearance and weight.

N reported having had poor body image and disordered eating patterns since the age of 7. She stated that she was always self-conscious about her eating habits and relationship with food as a child because her mother was very critical of her weight, shape, the amount of foods she ate, and the way she ate. N reported a history of cocaine abuse that began when she was 16 years old. She recalled that her first cocaine use was supplied by her mother. She snorted cocaine twice a week with either her mother or friends until she was 30 years old. In the past 5 years, N stated that she typically used cocaine in solidarity after a binge drinking episode and when she needed a “pick-me-up.” N admitted that cocaine use was related to her ED because of the drug’s appetite-suppressing effect. N stated that she started feeling depressed and hopeless when she was 23 years old, while attending college. These depression symptoms were related to her disordered eating behaviors and shape/weight concerns, as well as a lack of accomplishments and meaningful relationships. She stated that she was always “impulsive, impatient, and distractible” but denied having had any hypomanic or manic episodes in her lifetime.

With regard to her treatment history, N began residential treatment 8 months prior to seeking IOP treatment. Upon a successful completion of this 2-month residential program, she stepped down to PHP level of care for an additional month for alcohol and cocaine use disorders and bulimia nervosa. N maintained normalized eating patterns and abstinence from all psychoactive drugs during these programs. She began regular individual outpatient therapy for continued care but relapsed in bulimic symptoms and alcohol misuse a few weeks post PHP. With this relapse, N’s psychiatrist referred her to a primarily substance use–focused IOP program; however, it was N’s impression that she was discharged within a week because she met inclusion criteria for an ED. According to blood tests and self-report, N was compliant with Trileptal and reported feeling more even-tempered while on this medication. In addition, she was prescribed Naltrexone to manage her alcohol use and cravings, but N was noncompliant with this medication due to reported side effects.

5 Assessment

N received a structured intake interview by a licensed clinical social worker to assess her presenting problems, current functioning, level of needs, and appropriateness for IOP treatment. At the time of intake assessment, N’s body mass index (BMI) was 27.1, calculated using her height and blind weight measurement. N tested negative for all substances on a baseline urine drug screen. N provided information of her current symptoms and history of these complaints, substance use history, and mental health and medical history. She also provided information on her family’s medical and psychiatric history, and her psychosocial background, and she completed a Mini-Mental Status Examination. In addition, N responded to a number of self-reported questionnaires on ED, mood, and anxiety symptoms. N’s answers on the Eating Disorder Examination-Questionnaire (EDE-Q; Fairburn, 2008; Fairburn & Bèglin, 1994) showed that she scored higher than the community norm in terms of global eating pathology, as well as restraint, eating concern, shape concern, and weight concern. Figure 2 summarizes N’s scores on the EDE-Q measured before IOP treatment. Her responses on the Eating Pathology Symptoms Inventory (EPSI; Forbush et al., 2013; Tang, Forbush, & Lui, 2015) further revealed that her levels of binge eating and excessive exercise were higher than clinical norms of general psychiatric patients and comparable with the norms of bulimia nervosa patients. In addition, she reported higher levels of body dissatisfaction, binge eating, and negative attitudes toward obesity than the norms from both anorexia and bulimia nervosa patients (see Figure 3 for a summary of these pretreatment scores and norm data). N’s self-reported mood and anxiety symptoms on the Patient Health Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002) and Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006), respectively, suggested that her feelings of depression and generalized anxiety fell in the severe range. These mood- and anxiety-related assessment data are summarized in Table 1. Based on her psychiatric history, assessment, and clinical evaluation, N’s symptoms and functioning at intake met DSM-5 criteria for bulimia nervosa and bipolar disorder not otherwise specified. She also met criteria for alcohol and cocaine use disorders in early remission.

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Table 1.

Summary Scores and Clinical Range of Depression and Anxiety Symptoms at Pretreatment, Posttreatment, and Follow-Up Assessments.

	Pretreatment	Posttreatment	Follow-up
PHQ-9	21 (severe)	2 (minimum)	2 (minimum)
GAD-7	21 (severe)	12 (mild to moderate)	4 (minimum)

Note. PHQ-9 measured depression symptoms; GAD-7 measured anxiety symptoms. PHQ-9 and GAD-7 items were rated on 0 (not at all) to 3 (nearly everyday), scores ≤4 indicated minimal levels of depression/anxiety, and scores ≥5, 10, 15, and 20 indicated mild, moderate, moderately severe, and severe levels of depression/anxiety, respectively. PHQ-9 = Patient Health Questionnaire-9; GAD-7 = Generalized Anxiety Disorder-7.

6 Case Conceptualization

Conceptualized in a biopsychosocial framework of psychopathology and the ICAT model of bulimia nervosa, N likely suffered from biological and personality predispositions resulting in highly intense negative emotions, impulsivity, and proneness to desire and seek positive affect. These vulnerabilities predisposed her to emotional difficulties and appeared to underlie all of her symptoms. N exhibited a pervasive sense of inadequacy and unstable self-identity. Not only did she experience greater intensity and frequency of negative affectivity such as depression, anxiety, stress, and loneliness than others in her age group, she also had greater difficulty in accepting these emotional experiences. She lacked effective coping strategies to manage these erratic emotions and therefore used binge eating and substances to “fill the void.” It was evident that her mother’s critical judgment of her weight and shape, along with her internalization of thinness ideal from her heritage culture, prompted and sustained N’s rigid body image.

The ICAT model provides a theory-driven and evidence-based explanation to the developmental, precipitating, and maintaining factors that contribute to N’s emotional experiences and symptoms (see Figure 1 for graphical presentation). The onset model took into consideration N’s individual characteristics as risk factors for developing bulimia nervosa and SUDs. Particularly, her family and cultural experiences and personality traits precipitated her tendencies to experience intense negative emotions, seek positive affect, and to be impulsive. N likely learned from her mother that substances and binge eating could reduce negative emotions, given her mother’s and her shared substance use history and meta-emotion philosophy.

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Figure 1.

Modified conceptual model of the integrated onset-maintenance of disordered eating and substance misuse symptoms consistent with the integrative cognitive-affective therapy (ICAT) framework.

Given the emerging research on the plausible mediational role of meta-emotions in the relations among personality traits, emotional experiences, and maladaptive behaviors (Mayer & Stevens, 1994), N’s evaluation of her emotional states was considered an important element in understanding her motivations underlying disordered eating patterns and substance misuse tendencies. Specifically, N’s daily monitoring forms and behavioral chains of problematic behaviors (mostly binge eating) showed that her intense negative emotions such as depression and self-criticism were exacerbated by her negative meta-emotions surrounding loneliness, anxiety, hypomania and mania, and perceived stress. Her nonacceptance of these affective responses—in conjunction with her maladaptive expectancies to avoid or alleviate them through binge eating and substance use—sustained N’s ED and SUD symptoms.

7 Course of Treatment and Assessment of Progress

Consistent with the ICAT conceptualization model and treatment protocol, N participated in fifteen 60-minute individual therapy sessions in conjunction with dietitian and supportive group therapies, common in IOP settings. Throughout the course of treatment, N was engaged in 9 hr of group therapies ⁴ (i.e., 3 times per week and each group therapy session lasted 3 hr).

During Phase I of the treatment, N was provided with an overview of the therapeutic approach and psychoeducation about the etiology and symptoms of ED and SUD. Particularly, she gained insight about the maladaptive nature of excessive exercise as a compensatory mechanism to control for weight gain. The therapist used motivational interviewing to promote N’s engagement in treatment and establish a positive therapeutic alliance. N responded well to the therapist’s empathy surrounding her chronic struggles with eating-related problems and her willingness to make positive changes. N collaboratively established her treatment goals with the therapist. These goals included (a) gaining more knowledge about EDs and other maladaptive behavioral patterns, (b) decreasing purging and excessive exercise, and (c) maintaining abstinence from cocaine and limiting alcohol consumption to normalized drinking. N also wished to be content with her self-image and identity, and to learn to be more relaxed.

N was introduced to a Daily Food and Emotion Record to track the time, types, and content of her food and alcohol intake, as well as her emotions and other pertinent information regarding her environment. Through regular practice with daily records outside of therapy and discussions with the therapists during individual sessions, N identified that she tended to “feel bad for at least one extra day” if she engaged in binge eating episodes because of self-blame and shame. In Session 3, N reported that she had 2 standard drinks during a 1-hr work break because she was bored and lonely. Despite having a moderate level of craving, she did not seek cocaine after considerations of the various consequences. During the early phase of treatment, N was somewhat ambivalent about the severity of her alcohol use, and denied that boredom may be an emotional trigger for her alcohol and cocaine use.

Through the Daily Food and Emotion Record, N identified a number of key negative emotional experiences that she struggled with: anxious, inadequate, ashamed, and depressed. She learned that her maladaptive coping behaviors such as eating pathology and substance misuse functioned as an avoidance of psychological and physical discomfort. One of the primary feelings that N found intolerable was loneliness as it meant that she was “pathetic,” “undesirable,” and “a loser.” She stated that coming home to her apartment without a romantic partner and close friends triggered a strong sense of loneliness; therefore, she frequently felt the urge to “fill the emptiness with foods.” She also realized that she tended to become argumentative and defensive in interpersonal relationships when she felt inadequate, criticized, and worthless; all of which were incongruent with how she would like to perceive herself. Using situations where she experienced intense negative emotions and then engaged in a problem behavior, N was introduced to the behavioral chain analysis to understand the environmental and internal (thoughts, physiological sensations, and/or affective states) cues that prompted her maladaptive actions. The therapist also focused on helping N appreciate the discrepancies in her current and ideal self-view as a typical antecedent for her moment-to-moment negative emotions.

In the sixth session, N reported severe symptoms and consequences associated with a manic episode that took place over the weekend. For no apparent reason, she experienced a rush of euphoria, grandiose sense of self and attractiveness, racing thoughts, strong desire to feel wanted, and an impulsiveness to “do something super fun.” She engaged in binge drinking in solidarity and sought out casual sexual encounters. She spent US$100 purchasing cocaine from a dealer and engaged in cocaine use and heavy drinking for two consecutive days. N was extremely ashamed and self-critical of her slip in cocaine use, which led to multiple binge eating episodes.

N used the behavioral chain analysis to connect the vulnerable risks (biological and personality predispositions to seek and experience intense positive emotions), her manic state, and cognitive expectancies of substance uses and binge eating to the consequences of these maladaptive behaviors. Specifically, she identified the distorted beliefs that bulimic symptoms and substance abuse would make her feel less depressed and lonely. N closely monitored her erratic emotional states as triggers for high-risk behaviors. She also learned impulse control skills to manage her affective states and observe urges to engage in substance use, binge eating, and purging when experiencing negative emotions.

During Phase II of ICAT, the therapist focused on enhancing N’s emotional awareness, inhibiting her maladaptive behaviors, and promoting her ability to practice and effectively use adaptive coping strategies. N showed a high level of motivation in developing coping skills to manage her mood swings and impulsivity, and to decrease substance misuse and disordered eating behavior. She developed greater insight about the impact of her family experiences on her thinness ideal. Particularly, she reported that she learned to identify with her mother’s emphasis on thinness, attractiveness, and high levels of positive emotions at a young age. She also pointed out that her heritage culture valued thinness because being thin was “equated [to] a balanced lifestyle, health, and happiness.”

N continued to track her daily experiences, meal plan compliance in the Daily Food and Emotion Record, and indicate alcohol and substance use in a timeline followback format. She was introduced to self-soothing techniques, distraction and urge surfing to manage cravings, and pleasant activity scheduling for both behavioral activation and self-care. She practiced taking casual walks, listening to music, appreciating nature, reading, watching television, and spending time with her family. Therapy sessions provided a space for N to problem solve ways to use these new coping skills more effectively in situations she encountered throughout the week. Through collaboration with her dietitian, N maintained 85% meal plan compliance and reported an increased frequency of mindful eating. She remained abstinent from cocaine and reported occasional, normalized alcohol use (once to twice per week).

Sessions during Phase III were individualized to identify N’s emotional triggers, examine and challenge maladaptive meta-emotions, and explore ways to modify experiential avoidance and her affective regulation strategies. To better explore her emotional intelligence and existing emotion regulating styles, the therapist administered the Meta-Evaluation and Meta-Regulation Scales ⁵ (Mayer & Stevens, 1994) as a tool to assess and help N better understand her levels of emotional clarity and acceptability of various affective experiences.

The Meta-Evaluation Scale measures N’s reflection of her thoughts and feelings about her emotional experiences in four areas. N reflected on the clarity of her emotional experiences, the degree to which she could accept the emotions without changing them, the extent to which any given emotions were typical for her, and influence of the emotional states on her outlook on life. The Meta-Regulation Scales focuses on assessing N’s typical approach in regulating her emotional states. Specifically, N reflected on whether she was keen on repairing negative emotions and promoting positive emotions, and whether she tended to maintain affective states. N’s ratings on the Meta-Evaluation Scale showed that she was adequate in distinguishing her emotional states (M_Clarity = 3.17), and it was typical for her to experience sadness, loneliness, and self-criticism (M_Typicality = 3.00). Furthermore, N learned that these emotions tended to negatively affect her self- and worldviews in a given moment and in general (M_Influence = 3.00). Finally, she realized that she tended to have a high level of difficulty accepting these experiences (M_{Acceptability} = 1.50). Through reflection and discussing her ratings on the Meta-Regulation Scale with the therapist, N indicated a strong tendency to repair emotions that she deemed “negative” and “undesirable” (M_Repair = 4.20). In contrast, she was less prone to maintain or accept negative emotional experiences (M_Maintain = 2.80). Specifically, she believed strongly that any negative emotions such as loneliness, anxiety, and sadness were harmful and not normative to other people’s experiences.

In therapy, N reflected on how meta-emotions precipitated her high levels of experiential avoidance and maladaptive coping through bulimic symptoms and psychoactive substances. N identified having unrealistic standards for “having it all together.” She said, “It has always been my belief that I must be calm and collected at all times and have a successful career and a happy romantic relationship.” N recalled how her mother constantly compared N with her sister and praised her sister for being intelligent, beautiful, and thin. As a result, she learned as a child that having negative emotions meant that people were undesirable, unhealthy, and weak; she thought it was wrong and shameful for her to have negative emotions, and that she was supposed to be joyful and confident at all times. N came to realize that these negative meta-emotions and the discrepancies in her current and ideal self-views led to feelings of depression and anxiety. Her propensity to experience intense emotions and a lack of efficacy to regulate them added to persistent self-blame and criticism. She frequently felt the need to punish herself because she did not feel normal, which resulted in her tendencies to suppress negative emotional experiences through binge eating and substance misuse.

N reported that this contextualization and reflective exercise enhanced her understanding of her meta-emotions. She also indicated that this discussion about her meta-emotion philosophy not only decreased her self-criticism but also promoted her ability to accept her personality tendencies and various emotional experiences. She learned and practiced cognitive restructuring skills to challenge these maladaptive meta-emotions and her negative reactions to moment-to-moment affect. The therapist introduced gratitude journaling and self-compassion skills, and encouraged her to embrace her personality traits and affective experiences with a gentle stance. It was evident that by the end of Phase III of treatment, N was able to mindfully observe her emotions without the impulsive tendencies to escape or alter them.

In Phase IV, N participated in weekly outpatient individual therapy following a step-down from IOP. To maintain treatment gains and sustain her motivation to work on her recovery, N was introduced to the Values Card Sort exercise to clarify her core values in life to keep promote her recovery efforts. She identified “Family,” “Purpose,” and “Accomplishments,” as values that motivated her. Furthermore, N continued using gratitude journaling as a core coping skill to break the cycle of suppressing negative emotions with maladaptive behaviors. She denied any drinking episodes or cocaine use during this period. She admitted to her brother about her alcohol abuse, which was the first time she had openly acknowledged that her alcohol use was problematic. N continued practicing impulse control skills from ICAT, used pros and cons lists to discourage herself from drinking when she experienced moderate levels of cravings, and reinforced her use of effective emotion regulation strategies (e.g., relaxation and talking with her family members). She stated that she had one to two “emotional eating” episodes, which were not accompanied by dissociation, guilt, or shame. Based on her daily records, these did not constitute objective binge episodes. In addition, N reported having less intense feelings overall, and found self-compassion and radical acceptance helpful when she experienced negative emotions. She said, “I now understand that it’s okay to experience negative feelings. The meta-emotions came from my culture and my mom. I am more gentle with myself.”

At the end of treatment, N’s symptoms fell in the subclinical range for weight and shape concerns, body dissatisfaction, and binge eating behavior. Her weight maintained at 177.5 pounds (BMI = 27.0). She also showed the greatest improvement in dietary restraint, purging, and alcohol use. Timeline followback indicated that N had no more than 6 alcoholic drinks in the past month and was abstinent from all other substances. Finally, her ratings for depression fell in the minimum range, and her ratings for anxiety were in the minimum-to-moderate range. Table 1 and Figures 2-3 summarize these posttreatment clinical outcomes.

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Figure 2.

Scores on the Eating Disorder Examination-Questionnaire (EDE-Q) at pretreatment, posttreatment, and follow-up assessments, and community norms for comparisons.

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Figure 3.

Scores on the Eating Pathology Symptoms Inventory (EPSI) at pretreatment, posttreatment, and follow-up assessments, and bulimia nervosa (BN) and general psychiatric norms for comparisons.

8 Complicating Factors

At the time of admission and throughout the first five sessions, N carried a diagnosis of bipolar disorder not otherwise specified because there was no clear evidence of manic or hypomanic episodes in her lifetime. She experienced a manic episode during Week 6, which triggered a 2-day prolonged binge drinking episode and cocaine use, binge eating and purging, and unsafe sex. The diagnosis was revised to bipolar I disorder, and she received a higher therapeutic dose of Trileptal to stabilize her moods. The therapist’s debriefing with N regarding this manic episode allowed her to better understand her biological and personality predispositions and triggers of maladaptive behaviors.

Although N did not meet diagnostic criteria for borderline personality disorder, she displayed some related characteristics including marked negative self-view, impulsive destructive behavior (i.e., binge eating, substance misuse, unsafe sex, and spending sprees), chronic feelings of emptiness and loneliness, and high level of emotional instability. N also was easily distractible, disorganized, and impulsive during and outside of therapy; these symptoms reduced but remained problematic even after a successful mood stabilizer regiment was implemented and maintained. The therapist adapted to N’s style by using active and collaborative treatment planning, using reminders and tangible worksheets, and engaging N with motivational interviewing techniques throughout the course of treatment.

9 Access and Barriers to Care

N maintained health care insurance benefits and access to physical and mental health care throughout the treatment duration. She was recommended to PHP following a relapse in her substance use; however, she declined this recommendation, fearful of another extended medical leave and potential termination from her employment. Given that N’s full-time employment and health care benefits were two of her assets, N was motivated to actively engage in treatment at an IOP level while navigating other demands in her life.

10 Follow-Up

At 1-month follow-up, N reported having had no more than three subjective binge eating episodes and one purging episode since treatment termination. She denied any cocaine use or cravings. N reported having had one alcoholic drink in the past month. She stated that her moods had been positive but stable, and she did not experience any severe depression or (hypo)manic episodes. In spite of a number of new stressors associated with work, a minor automobile accident, and the hassle of moving into a new apartment, N was able to monitor her emotional states and urges for high-risk behaviors. She continued to follow her meal plans and use adaptive coping skills. Her scores on the Meta-Evaluation and Meta-Regulation Scales indicated an improved level of emotional acceptance. N continued to refute her previous expectancies that binge eating and substance use would help regulate her emotions. She was able to tolerate intense negative emotions through distraction, self-compassion, and constant reminders of a healthy self-view and her core values. N weighed in at 178.5 pounds (BMI = 27.1). Based on this assessment at follow-up, N was in partial remission for bulimia nervosa and early remission for alcohol and cocaine use disorders. Her self-reported ratings suggested that she experienced minimal depression and anxiety symptoms.

11 Treatment Implications of the Case

Results suggested that ICAT may be a viable intervention with a coherent, evidence-based theoretical framework to address transdiagnostic risk factors underlying eating pathology and substance abuse. In complex cases such as this, ICAT is likely to outperform CBT-E by outlining specific behavioral strategies to reduce disordered eating and incorporating techniques that target impulsivity, novelty seeking, and behavioral inhibition deficits that underlie bulimia nervosa, alcohol and substance use, and bipolar disorders (Accurso et al., 2016; Gregorowski et al., 2013; Smith, Mattick, Jamadar, & Iredale, 2014). The present case study provided preliminary evidence for the potential benefits of ICAT in reducing symptoms and improving psychosocial functioning for people with comorbid ED and SUDs in two ways.

First, N’s therapeutic gain at the end of treatment and at 1-month follow-up suggested that ICAT may be used to treat individuals with comorbid bulimia nervosa, SUDs, and bipolar disorder—the latter two were considered exclusion criteria in previous randomized controlled trials for ICAT (Wonderlich et al., 2014). Individuals with SUDs are often referred to rehabilitation facilities that treat chemical dependency prior to addressing other co-occurring mental health issues, and ED treatments often exclude people with moderate to severe SUDs. Results from this case suggest the promise of treating both ED and SUDs simultaneously using a similar set of therapeutic techniques in ICAT. This is likely an economic and clinically appropriate approach that will allow therapists and individuals to work on issues that underlie and maintain symptoms in both disorders.

Second, despite the homogeneous, White American women sample in the ICAT randomized controlled trial (Wonderlich et al., 2014), the present case suggested that ICAT may be effective in treating Latina women with comorbid eating, substance use, and mood disorders by systematically addressing negative affect and self-view, emotional dysregulation, and maladaptive expectancies regarding bulimic and substance use symptoms.

The clinical outcome of this case also showed the promise of analyzing the functional importance of meta-emotions in experiential avoidance and maladaptive behaviors associated with bulimia nervosa and substance misuse. Meta-emotions have been examined systemically in family and parenting research; it appears that it also has the potential of illuminating the development and maintenance of psychopathology such as addiction (Shaver et al., 2013; Spada & Wells, 2010) and disordered eating. The present case shows that meta-emotion philosophy can be an important and clinically useful concept to help individuals clarify the basis of their negative feelings about various emotional states. By challenging unhealthy meta-emotions, individuals may then identify ways to modify experiential avoidance tendencies.

To the extent that N was treated with ICAT augmented with cognitive restructuring surrounding meta-emotions in tandem with other supportive therapies in an IOP setting, the format of treatment delivery and the patient’s therapeutic gains should be considered with such context in mind. First, the standard protocol for ICAT requires a minimum of 21 individual sessions with each session lasting for 45 to 50 minutes (Wonderlich et al., 2015). The course of treatment in this case spanned 15 sessions (excluding the follow-up session) with each session lasting for 60 minutes. The overall time spent during the course of treatment was similar in this case as intended in the empirically supported manual; however, the distribution of session time differed because of N’s circumstances, needs, and IOP setting. Specifically, rather than utilizing 2, 6, 11, and 2 sessions for Phases I, II, III, and IV, respectively, as suggested in the ICAT treatment manual, significantly more time was spent on Phase I with N. This was due to the need to orient N to the multidisciplinary therapeutic environment, and the incident where N experienced a full-blown manic episode during Week 6 of her treatment. Consistent with the standard treatment protocol, the most intensive therapeutic action occurred during Phase III; this was when N learned about the role of meta-emotions and her negative self-evaluation in bulimic and substance use behaviors.

The supportive dietitian therapies and group therapies permitted an accelerated pace for Phases II and III of ICAT in this case. Meal planning, regulation of meal consumption, and monitoring of substance use behavior were primarily discussed and reinforced in individual dietitian sessions; thus, more focused time was spent on developing adaptive coping strategies for urge control in individual sessions with the primary therapist during Phase II. Furthermore, it appeared that N benefited greatly by the systematic examination and challenge of her negative meta-emotions during Phase III. N was able to continue reflecting on triggering events and ways to adaptively cope with them, and practice other self-regulation skills in supportive group therapy. Given these additional treatment components and support from other clinical staff and fellow patients, it is possible that N received better clinical outcomes at a faster pace than typically seen in an individual outpatient context. Nonetheless, this is the first case study that describes how ICAT can be beneficial in reducing co-occurring ED and SUD symptoms in a Latina American in a clinical setting.

12 Recommendations to Clinicians and Students

Consistent with the ICAT format, it is recommended that motivational interviewing be practiced throughout the duration of treatment, particularly with individuals who are ambivalent about changes in some aspects of their mental health (Vall & Wade, 2015). After a lapse of cocaine use and binge drinking, N was feeling extremely ashamed and discouraged. She indicated that the therapist was not blaming but instilled optimism in her, which was instrumental in ensuring a positive therapeutic alliance and a sense of hope in recovery. In addition, for patients who struggle with multiple forms of psychopathology, focusing on treatment gains in a variety of symptom areas can be overwhelming and challenging. Thus, it would be important to highlight and reinforce individuals’ effective use of coping skills throughout the course of treatment despite the lack of immediate symptom reduction.

The present case report suggests that understanding meta-emotions is an important step to explore individual determinants to emotional regulation strategies based on people’s beliefs and valuation of related emotional experiences. When individuals appreciate the reasons that they avoid these intense emotional experiences, they not only can begin to challenge this meta-emotion belief system and the maladaptive functions of disordered behaviors but also develop effective emotion regulation strategies in therapy. Reconstructing meta-emotion philosophy and subsequently reshaping the tendency to rashly reduce negatively evaluated emotions with maladaptive behaviors seemed to support the research linking negative urgency and bulimic symptoms (Fischer, Smith, & Cyders, 2008).

Finally, the emphasis on moment-to-moment emotions and cognitions was shown to be beneficial to N’s therapeutic gain; it was clear that she also benefited from a systematic and integrative understanding of the impact of her personal and cultural backgrounds on the onset and maintenance of her psychopathology. Clinicians and researchers should focus on how personality and cultural characteristics may shape patients’ emotional and behavioral patterns, as well as responses to a manualized treatment like ICAT (e.g., Cheng & Merrick, 2017). This sensitivity should promote cultural competency and effectiveness in interventions through the enhancement of therapeutic alliance (Flückiger et al., 2013).