Dialectical Behavior Therapy for Binge Eating and Bulimia (10 page)

1This differs from standard DBT (Linehan, 1993b, p. 23), in which clients who miss 4 weeks of scheduled
skills training sessions in a row are dropped from treatment.

The Pretreatment Stage

Asking about the Client’s Prior Treatment Experience
We recommend inquiring about the client’s prior therapy experiences. The therapist might say, “I am going to give you a general idea of the treatment, but frst
I’d like to learn more about you. Have you been in a group before? Have you been
in one like this? If yes, what did you like or did not like? Are there any issues
you foresee?” In our experience, it was not unusual for clients to have obtained
support for their eating concerns through such groups as Overeaters Anonymous,
Weight Watchers support groups, and/or therapist-led groups. Therapists may
wish to emphasize, particularly if clients report a negative past experience with
such groups, the differences between this current treatment approach (i.e., a struc—
tured, skills-based group with an eating-disorder focus) and what they have tried.
We also try to help clients cope ahead of time with any reported diffculties they
have experienced with past treatment attempts.

Introducing the Emotion Dysregulation Model
We have found it helpful to introduce the emotion dysregulation model of problem eating (i.e., binge eating and/or purging; Appendix 3.1) by having the client
describe a typical problematic eating episode and using this as a basis for assess—
ing the model’s personal relevance and ft for the client. The therapist might commence as follows: “Now I would like to ask you about a recent or typical binge [and
purge]. Can you describe in as much detail as possible what was going on for you
at the time? What circumstances preceded the binge [and purge]? What feelings
were you having?”

Following the client’s description, the therapist presents the emotion dysregulation model of problem eating (see Appendix 3.1) and uses particulars from what
the client has revealed to describe the fow of events.

During the discussion, the therapist looks for opportunities to make the following points:

••
“This model assumes that emotions are reactions to internal or external
events. In other words, something in your environment, such as an argument, and/
or something in yourself, such as your thinking, triggers an emotion or set of emotions.”

••
“Emotions, whether they are negative emotions such as sadness or anger or
positive emotions like happiness or joy, can be uncomfortable. Feeling any emotion
too strongly or too intensely can be diffcult and therefore requires skillful emotion
regulation.”

••
“An assumption of this model [and one that seems to be accurate based on
what I’m hearing from your description of the binge ... ] is that you have not devel—
oped the means and are therefore frequently ill equipped to manage your emo—
tional experience. At least at times, you just don’t have the skills you need to toler—
ate how you feel.”

••
“Furthermore, because of all the times you’ve turned to food in the past,
you have a low expectancy
that you can handle your emotions any other way than

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
through using food. So you have uncomfortable emotions, and you don’t believe you
can handle them or soothe yourself.”

••
“You’ve come to believe that the only option you have is binge eating [and
purging] as a way of coping with your emotions. It becomes a sort of automatic,
overlearned behavior.”

••
“Temporarily, binge eating [and purging] may lead to a decrease in the distress by giving you a way to avoid how you feel, a means of escaping for the moment.
You don’t have to face your emotions or put in an effort to cope with them because
the food serves to distract you.”

••
“In the short term, binge eating [and purging] works to ‘solve the problem’ of
managing uncomfortable emotions. But in the long run, which is why you’ve come
for treatment, there is a high cost. For example, binge eating [and purging] often
leads to feeling guilt and shame, which can lead to more binge eating [and purging] and feeling hopeless. Your self-confdence is diminished and your expectation
that you can handle diffcult feelings is further eroded.”

••
“Skillful emotion regulation behaviors include the ability to monitor, evalu—
ate, and modify your emotional reactions. They also include the ability to accept
and tolerate emotional experiencing when nothing can be changed immediately.
These adaptive emotional coping skills may reduce the experience of an emotion
before it starts in the frst place and may modify the behavioral expression of an
emotion that has been experienced. Overall, the goal is to manage your emotional
experiences and behaviors in a way that leads to achieving your life goals.”

••
“This treatment will help you express emotions and enable you to live your
life without using food as a solution to emotional distress. We also assume that
some problems can’t be solved, but that it’s better to live with the problem than
to turn to a destructive solution. In this treatment you will learn to replace your
maladaptive responses with adaptive emotion regulation strategies.”

After making the preceding points, the therapist asks questions to facilitate
the client’s beginning to incorporate the model and rationale into his or her think—
ing. For example: “What do you think of this model and the assumptions of this
treatment? Does it seem to ft for you? Are there ways in which it does not make
sense?”

Orienting the Client to the Goals of Treatment, Goals of Skills Training,
and
Treatment Targets Handout

Once the client understands the treatment model, the therapist can review the
Goals of Treatment, Goals of Skills Training, and Treatment Targets handout
(Appendix 3.2). It is essential for the therapist to link the client’s goals and the
treatment targets to the learning and practicing of the skills. For example, the
therapist might point out:

“What is really important to you and the reason you joined this program is that
you want to stop binge eating [and purging]. If you just stopped binge eating
[and purging] without developing skillful means to cope with your emotions,

The Pretreatment Stage

another dysfunctional, maladaptive behavior could emerge in the place of binge
eating [and purging]. The basic premise of this treatment program is that by
learning and practicing adaptive and skillful ways to cope with your emotions,
you can use the skills to replace your maladaptive binge eating [and purging],
other problem eating behaviors, and other maladaptive means you currently
use to cope with your emotions. This treatment focuses on helping you acquire,
strengthen, and apply adaptive skills for gaining emotional control to elimi—
nate the need to rely on strategies such as binge eating [and purging].”

Sarah, for example, the harried mother of two, would become more aware of her
emotional state by observing muscle tension in her back and shoulders.

The therapist begins at the top of the handout, reading and discussing each
point. The client’s agreement and commitment to each major aspect of the treatment is elicited before moving on. In our experience, the client’s commitment to
the treatment goals and targets during the pretreatment interview is, for the most
part, straightforwardly obtained. For example, after the therapist orients the client to the goals of treatment (e.g., saying, “In this treatment, the primary goal is
to stop binge eating [and purging]. This is the top priority. The goal also includes
control over other problem eating behaviors, as I’ll describe,” and asking, “But frst,
do you agree with this overall goal?”), we have found it very likely that clients in
our treatment studies will readily agree. However, some clients may be hesitant.
If it seems helpful, reassure them that although they need to be 100% certain of
the goal to stop binge eating (and purging), they may simultaneously be uncertain
about their ability to accomplish this goal. Here is where therapy and learning the
skills will help the clients out. These are the means by which they will meet their
goals.

In DBT for BED or BN (as in standard DBT), commitment is viewed as a
process, a behavior to be elicited, learned, and reinforced. In the pretreatment
interview, the therapist frst and foremost is encouraging a commitment to treatment. The commitment to the treatment targets and goals is also encouraged and
strengthened during the frst introductory session.

When attempting to secure a commitment to the goals of skills training
regarding learning and practicing the skills, the therapist might explain, “The
goal of skills training is to learn and practice adaptive emotion regulation skills.”
The therapist will be satisfed and move on if the client agrees when asked: “Does
this make sense to you? Do you agree to this goal?” For most clients, the orienta—
tion to the emotion dysregulation model of problem eating is suffciently relevant to
the client’s understanding of his or her problematic eating that a goal of learning
skillful emotion regulation behaviors is logical.

Orienting the Client to the Path to Mindful Eating

The therapist explains, “We call this the ‘path to mindful eating.’ By ‘mindful
eating,’ we mean eating with awareness, in the present moment. Mindful eating
is the opposite of binge eating—which is eating without awareness or a sense of
control.” In order to help clients effectively achieve the capacity to eat mindfully,

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
the following treatment hierarchy has been established. At the top of that hierarchy is stopping any behavior that interferes with the client’s ability to receive
treatment.

Stopping Any Behavior That Interferes with Treatment
Highlight the idea that any behavior that interferes with participating effec—
tively
in
treatment will be the top priority of treatment. The therapist might
explain:

“I know you’ve committed to stopping binge eating as your overall goal. At the
same time, if you are not feeling like coming to sessions, if you are missing
sessions, are not doing your homework or are not practicing the skills—these
issues would need to be addressed frst. You are learning how to stop binge eating, and we both know that if you could have done this on your own, you would
not be here. So, part of our job together is to identify anything that is getting
in the way of treatment and to work on it. How can you learn the skills if you’re
not here, right? Can you agree to that, that this is the top target on your path
to mindful eating?”

Stopping Binge Eating (and Purging)

The therapist explains, “When we talk about binge eating, we are referring to eating a large or small amount of food in which the predominant experience is being
out of control.” The therapist makes reference to the previously discussed “typi—
cal binge” used to illustrate the emotion dysregulation model of binge eating. The
behaviors of purging and/or other compensatory behaviors (e.g., using laxatives or
diuretics, fasting, overexercising) are targeted here, too. The therapist might say,
“Stopping these behaviors is essential to gain an improved quality of life. Do you
agree with that goal?” In our experience, most clients nod in agreement with this
goal despite admitting some nervousness. After obtaining agreement, the therapist then explains that the remaining behaviors are targeted because they are
believed to set clients up to binge eat (and purge).

Eliminating Mindless Eating

Defne mindless eating as eating without the awareness that one is eating, or eating
on “automatic pilot.” This includes overeating or eating when one is not physically
hungry and is not paying attention (such as when watching television). Mindless
eating can also involve chaotic eating, such as snacking throughout the evening
because one has not planned a meal. Mindless eating is not equivalent to binge
eating, because it does not entail the experience of a loss of control. However, mindless eating frequently leads to binge eating (and purging). For example, mindless
eating would involve a client noticing, after the fact, that a whole bowl of chips has
been emptied without recalling having eaten them—prompting feelings of shame
and hopelessness. This might lead the client to cave in to an urge to binge (and
purge). The therapist might ask, “Have you ever done this kind of eating? Do you