Dialectical Behavior Therapy for Binge Eating and Bulimia (11 page)

The Pretreatment Stage

agree with making this a target?” Usually clients nod in agreement and verbalize
having similar experiences.

Decreasing Cravings, Urges, Preoccupation with Food
Clients tend to focus on or ruminate about food. This treatment assumes that
such behaviors function to distract clients from distressing emotions. The therapist explains that cravings, urges, and food preoccupations are ineffective means
of coping with emotions. Over time, these unattended cravings, urges, and food
preoccupations can build in intensity and lead to binge eating (and purging): “Do
you think this applies to you? Does it make sense to decrease that behavior? Do
you agree to target it?” Clients usually respond that they are greatly troubled by
cravings, urges, and preoccupations with food. Says Meredith, age 32, “I feel that
certain foods, like chocolate, call out my name! It would be great to learn how to
turn that off!”

Decreasing Capitulating

Capitulating is the state of mind that involves giving up or surrendering to food
and eating. As the therapist explains:
“Capitulating may seem like a passive behavior, but it is an active decision
to close off your options to not binge eat [and purge]. The fact is that you
always have a choice
to binge eat [and purge] or not to. When capitulating,
you are deciding
to shut down, give up, and pull the covers over your head.
Does decreasing capitulating make sense to you? Do you agree to target that
behavior?”

Simon, age 42, expresses his experience with capitulating: “I end up saying ‘Screw
it! I’m tired of battling this!’ And then I get off the highway, go to McDonald’s, and
end up eating four cheeseburgers in my car.”

Decreasing Apparently Irrelevant Behaviors
An apparently irrelevant behavior (AIB) is a behavior that, upon frst glance, does
not seem relevant to binge eating (and purging) yet actually is an important com—
ponent in the behavior chain leading to a binge (and purge). “This is when you tell
yourself that your behavior does not matter, but deep down, you know it is setting
you up.” For example, Janet, a 52-year-old divorced mother, describes a typical AIB
as bringing home leftover food from the offce “for my son,” despite the fact that she
will most likely be the one to consume it. Another typical example would be buy—
ing dessert “for company” if the client is convincing him-or herself that it will be
eaten by others while knowing from experience that she will likely eat it herself.
Another AIB, typical of many overweight binge eaters, is avoiding the scale. By not
weighing themselves, clients deprive themselves of important feedback regarding
the consequences of their eating behaviors—making it easier to pretend that the
binge-eating behaviors do not “really matter that
much.”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Increasing Skillful Emotion Regulation Behaviors2

The therapist explains that to help clients stop bingeing and take control over
their eating behaviors, treatment will involve teaching adaptive emotion regulation behaviors. These skills are taught over three modules.3

MINDFULNESS
S
KILLS

Mindfulness skills facilitate the client’s nonjudgmental observation, description,
and experience of the current moment without having to do something to escape
from it. “The basic concepts in this module are awareness and being in the pres—
ent moment. Mindfulness skills can help you become more aware of your urges
to binge [and purge], can help you reduce your self-judging, and can be used to
replace binge eating, mindless eating, and other problem behaviors.”

EMOTION
R
EGULATION
S
KILLS

The skills taught in this module help the client more adaptively manage his or her
emotions and break the link between emotions and problematic behaviors. The
therapist elaborates:

“The emotion of sadness, for instance, may be linked to certain behaviors, such
as withdrawing and binge eating. The emotion regulation skills will teach you
to experience such emotions—getting through them instead of avoiding them.
Other skills involve acting in ways that are ‘opposite’ to your current emotion,
such as becoming active rather than withdrawing. Also, even though turning
to food ultimately makes you feel worse, it may also feel like your only source
of pleasure. The emotion regulation skills teach ways to increase your positive
emotions in healthy, enduring ways that will not backfre as binge eating does.
Do these skills seem relevant to you? Do you agree to learning them?”

Typically, clients are emphatic in their agreement that these skills, especially, are
relevant. Though not always (see the section on troubleshooting later in the chap—
ter), clients usually are able to identify the link between feeling overwhelmed by
their emotions (both positive and negative) and turning to food, though they are
at a loss as to how to cope otherwise. The idea of specifc emotion regulation skills
often provides hope that through treatment they will have new and more effective
ways to respond to their emotions.

2The goal of increasing skillful emotion regulation behaviors broadly refers to increasing all the adaptive
skills taught (e.g., Mindfulness skills, Emotion Regulation skills, and Distress Tolerance skills)—not only
those taught in the Emotion Regulation module.

3The adapted treatment described in this book involved teaching three skills modules, not the four of
standard DBT (see also Introduction). The Interpersonal Effectiveness module was omitted due to time
constraints and to limit theoretical overlap with IPT. Interpersonal issues are highly relevant with eating—
disordered patients, and clinicians who wish to teach this module can fnd justifcation from a clinical
standpoint. At this point, however, the inclusion of the Interpersonal Effectiveness module in this adapted
treatment has not been the subject of empirical testing.

The Pretreatment Stage

DISTRESS
T
OLERANCE
S
KILLS

These skills teach the client different ways to tolerate discomfort and distress
when nothing can be done to change the situation in that moment. Distress toler—
ance skills include acceptance skills and skills for surviving crises.

“Not making things worse by turning to food during diffcult times is an essen—
tial skill. This may mean sitting through painful emotions and urges to escape
pain by observing your breath instead of turning to food. Or, in situations
in which you feel emotionally overwhelmed, it may involve strategies such as
taking a break or self-soothing. Does learning the skills in this module seem
important to you? Do you agree to learn and practice them so that you can bear
pain more skillfully instead of making matters worse with binge eating?”

Simon, who tends to binge on fast food, is typical when he says, “I hate pain! Food
makes me feel better in the moment. You have your work cut out for you in teaching
me something else! But if you can, more power to you! I’ll give them a try.”

Therapists should make it clear that the client is being asked to commit to
learning and practicing all
the skills taught during the treatment. The therapist
may point out how, ultimately, of course, it is the client’s choice as to which skills
to continue using once treatment ends. “But you have to have be able to learn and
practice all the skills in order to fnd out which will work best.”

Following the Path to Mindful Eating

Summarizing the handout, the therapist introduces the client to research showing
that not
binge eating leads to weight loss or weight stabilization. Specifcally, when
abstinent from binge eating, clients with BED are more likely to lose weight, and
clients with BN typically stabilize their weight (i.e., stopping purging and other
compensatory behaviors does not lead to the weight gain often feared). In addition,
the therapist points out (discussed in greater detail in the section on weight loss
later in the chapter) that the benefts to stopping binge eating should improve the
client’s mood, self-esteem, and quality of life. That is, ultimately, why the client has
come for treatment.

Orienting the Client to General Treatment Issues

The therapist orients the client to the general goals of treatment by saying something such as “Treatment focuses on helping you to acquire, strengthen, and apply
adaptive emotion regulation behaviors to eliminate your need to rely on binge—
ing.” Treatment is structured, with each session having a specifc agenda. The
client will likely fnd this approach quite different from others tried in the past,
especially the client who has participated in “support” or “process” groups. As the
therapist describes, therapy is not intended to explore the client’s childhood experi—
ences in depth nor to cover all aspects of the client’s current life. In this treatment,
therapist and client concentrate on issues that relate to the client’s problem eating
behavior. Clients typically do not raise concerns regarding the therapeutic focus.
Indeed, many clients have had past treatment exploring their early childhood trau-

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
matic experiences and have noted that, although such treatment was quite helpful
in many respects, it did not impact their binge-eating behaviors.

Coming Late to Sessions

Coming late to sessions is disruptive to the course of treatment. If the client knows
he or she will be late, he or she should call the therapists beforehand. If the therapists have not received a prior message and the client is not present, one of the
cotherapists may call to check in. As the therapist explains, doing so allows the
therapist the opportunity to encourage a client who is experiencing strong urges
to engage in behavior that might interfere with the therapy to use skills she or
he has learned. The phone call to check in also helps allay the anxiety of group
members about the whereabouts of any missing group members. Discussing lateness emphasizes the seriousness of this type of therapy-interfering behavior. In
addition, the therapist needs to inform the individual client and the entire group
that a persistent pattern of lateness or any other behaviors felt to be disruptive to
treatment will be explored with the client.

The Therapist’s Need to Interrupt

The therapist informs clients entering group treatment that to ensure that each
individual has time to speak, the therapist may occasionally interrupt. Clients can
expect this behavior and are requested not to take it personally.

Weight Loss

As noted, overweight clients entering treatment tend to be quite concerned about
weight loss. The therapist validates the client’s concerns as quite understandable.
The therapist might add that he or she, too, worries about the client’s weight, as the
excess pounds refect an overuse of food to numb or avoid emotions. However, the
therapist makes clear that this treatment was not designed as a primary weight
loss program; diet, nutrition, and meal plans are not its focus.

However, as previously addressed in the Goals of Treatment handout, clients
who stop binge eating (and purging) and use adaptive skills to regulate emotions
typically experience weight loss and/or weight stabilization. Specifcally, the therapist may inform the client that during past trials of DBT for BED, clients lost an
average of 4 pounds over the course of treatment (Telch, Agras, & Linehan, 2001).
Clients who had maintained their abstinence from binge eating by 6 months fol—
lowing treatment lost an additional 7 pounds compared with those who relapsed,
who lost 1½ pounds (Safer, Lively, Telch, & Agras, 2002).

Depending on the level of the client’s concern regarding the treatment’s lack
of focus on weight loss or prescription of specifc diet plans, the therapist might
offer a more detailed rationale. Research with clients with BED has shown that
many do initially respond well to the structure of being placed on a diet and tend
to reduce their binge-eating behaviors. However, maintaining weight loss is dif—
fcult for many individuals, and those with BED are even more at risk of regain—
ing lost weight (e.g., being a “yo-yo” dieter). The fact that the client is presenting