Dialectical Behavior Therapy for Binge Eating and Bulimia (12 page)

The Pretreatment Stage

for treatment exemplifes that diets are not a cure. If this treatment were to place
the client on a diet, he or she might, indeed, do well. However, by virtue of not
having altered the fundamental dysfunctional pattern of binge eating in response
to emotional distress, the client would be at increased risk to regain that weight
and feel even more defeated. Instead, it is hoped that this treatment’s focus on
stopping binge eating will ultimately place the client in a much better position not
only to eventually diet but also to be able to maintain his or her hard-won weight
loss results.

In addition, the process of dieting itself is stressful and time-consuming. Shop—
ping for low-calorie foods, preparing meals, exercising—all necessitate effort and
dedication. Although the therapist agrees that reaching a healthy weight is impor—
tant, he or she wants to be realistic about what the client can achieve over the time
period of treatment.

For therapists not engaged in a research study, the decision to include a weight
loss component or to refer a client to a weight loss program (particularly after treatment has commenced and binge eating has improved but is not affecting weight)
could be made on a case-by-case basis. Chapter 9, on future directions for research,
includes a discussion of applying DBT when weight loss is a focus.

Weights of Group Members
Clients commencing group treatment occasionally express concern about how
much other members will weigh. The therapist stresses that participants are of
all weights and sizes. She or he can then go on to explain that all group members
share a problem with an eating disorder and use food to cope with upsetting emotions.

Does the Therapist Have an Eating Disorder?

Many therapists working with clients with eating disorders encounter this question. In our experience, no clear guidelines exist as how to best respond or, indeed,
whether there is an optimal answer. The therapist might express this situation to
the client by saying:
“Well, as I see it, there is not a satisfying way to answer your question. Let
me show you why. If I tell you that I don’t have an eating disorder, you might
worry that I couldn’t possibly understand your diffculties with eating enough
to help you and that I would judge you. But if I said that I did have an eating
disorder, you might worry that I wouldn’t be able to be of help to you because I
had exactly the same problem.”

Or the therapist might respond: “Almost everyone in our culture has used food to
cope with emotions—eating when we weren’t physically hungry but felt anxious
or bored. I’m hoping my not having an eating disorder won’t interfere with your
experience in treatment.”

In a similar vein, if the client appears uncomfortable and comments about
the therapist’s weight (e.g., “You’re so thin”), the therapist might observe that the

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
client seems to be comparing him-or herself to the therapist and making a judgment that could interfere with the client’s ability to successfully make use of this
treatment opportunity. The therapist might add that he or she sincerely hopes
the client will give the treatment a try despite experiencing discomfort and that
during treatment, he or she will be taught skills to help cope with these types of
judgments.

Patient and Therapist Treatment Agreements

The therapist hands the client a copy of the Group Member Treatment Agreements
(Appendix 3.3) or Individual Client Treatment Agreements (Appendix 3.4). Each
item is discussed to ensure that the client understands its rationale and to allow
for questions. These agreements will be reviewed in the introductory sessions,
and therefore a formal agreement is not sought during the pretreatment session.
Instead, the therapist asks the client to take the form home to read and think over
before bringing it back at the frst session.

The therapist discusses the Therapist Treatment Agreements (Appendix 3.5)
in a similar manner. These are also reviewed in Session 1.

Ending the Pretreatment Interview

Inquire whether clients have any questions that have not been answered or issues
they would like to raise. Then end the interview by expressing enjoyment over having met the client and by communicating enthusiasm for working together begin—
ning with the frst session—using the opportunity to remind the client of the spe—
cifc date, place, and time.

INTRODUCTORY SESSIONS

This section contains the material presented in the introductory sessions. In
our 20-session research trials, this material is covered during Sessions 1 and 2.
Depending on the number of sessions available and other potential factors, the
therapist might proceed more slowly. Of overriding importance is the use of these
introductory sessions—which complete the pretreatment stage of DBT for BED or
BN—to establish the foundation for the remainder of treatment.

Sessions are described for therapists leading treatment in a group format
unless otherwise noted. These descriptions can be straightforwardly modifed for
the therapist conducting treatment with an individual client.

In our groups, each client receives a three-ring notebook or binder. Hole-punched
handouts, distributed at each session, are to be stored in this binder, which clients
are instructed to bring with them to each session. We recommend that clients keep
the binder readily accessible. Not only might the sight of the binder remind clients
of their participation and commitment to treatment, but having it close at hand
also allows them to review the content of newly taught skills and facilitates their
keeping track of the work sheets by storing them in one place.

The Pretreatment Stage

43

The therapists begin by welcoming the clients to the treatment program and
expressing enthusiasm about embarking on this experience together. During the
pretreatment interview, each client entering group treatment will have met at least
one of the two cotherapists but may not have not met the other. Each cotherapist
should briefy introduce himself or herself by name, describe his or her background,
and, as relevant, mention his or her position in the research project or clinic.

Therapists then ask clients to take 1–2 minutes to introduce themselves by
frst name and give any personal information they may wish to share (e.g., inter—
ests/hobbies, occupation, whether they have children and/or a spouse). Clients may
also wish to comment on their hopes for entering treatment.

Commitment to Abstinence from Binge Eating (and Purging)
The next strategies are crucial. The therapists’ goal is to build a groundswell of
excitement in order to motivate clients and help them take the step to commit to
abstinence from binge eating (and purging). Therapists should convey the message
that abstinence from problem eating behaviors is absolutely essential if clients are
to have a high quality of life. In addition, therapists should express the frm belief
that this goal can be accomplished. Therapists are aiming, by the conclusion of this
discussion, to have elicited a verbal commitment from each group member to stop
binge eating (and purging).

The commitment strategies in DBT for BED or BN are the same as those in
standard DBT (Linehan, 1993a; i.e., Evaluating Pros and Cons, Playing the Devil’s
Advocate, Foot in the Door, Door in the Face, Connecting Present Commitments to
Prior Commitments, Highlighting Freedom to Choose in the Absence of Alterna—
tives, and Cheerleading). Defned briefy in Chapter 2, these are described in more
detail as particularly relevant. As noted, just as in standard DBT, motivation is
not
viewed as an internal state or intrinsic quality of the client. Instead, therapists
understand the necessary role of situational variables that, when present, increase
the likelihood that clients will exhibit a desired behavior (i.e., be “motivated”).
Therapists also keep in mind that eliciting commitment and agreement from a client is an ongoing task, requiring therapists to constantly gauge the client’s current
level of commitment and to return to the motivation and commitment strategies as
the client’s commitment waxes and wanes.

Evaluating Pros and Cons
is recommended as an initial technique to “sell”
the commitment to abstinence from binge eating (and purging). Therapists might
begin by stating:

“It’s so good to have you all fnally here! We assume that you are in this room
because you want to gain control over your eating behavior and stop binge
eating [and purging]. We’re also assuming that you want to have a full and
satisfying quality of life, one in which you enjoy your relationships, experience
a sense of mastery, and feel very good about yourselves most of the time. Binge
eating [and purging] is a problem because it interferes with feeling good about

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

yourself and having the high quality of life you desire, right? Yet there are
reasons why you turn to food. It has benefts. So let’s begin by making an hon—
est list of the pros and cons of continuing to be a binge eater [and purger]. The
point isn’t to stack the deck for one position or the other but to take the time
to really look hard at the advantages and disadvantages for you of continuing
this behavior. We’ll start with the pros. What is the pull to remain a binger
[and purger]? There must be advantages.”

One cotherapist elicits the “pros” from group members, while the other writes
these on a white board or large piece of paper. (Note: If conducting treatment within
an individual format, the therapist may list the pros on a piece of paper.) After
eliciting the pros of binge eating (and purging), therapists inquire about the cons:
“What are the serious disadvantages to remaining a binge eater [and purger]?
What types of things brought you into treatment?” Again, one therapist elicits
these and the other writes them down. Once the lists are created, therapists should
use the strategy Playing the Devil’s Advocate
to help solidify the motivation:

“Those pros look pretty darn compelling! We’re not sure we’d be able to fnd
a way to say to ourselves that we would work like heck to give up bingeing
[and purging]. Convince us—why can’t you continue to binge eat [and purge]
and still lead a highly satisfying life? Now, when we refer to this quality of
life, we’re not talking about a life in which you’re simply existing or ‘getting
through’ and trying to minimize pain. We’re talking about feeling fully alive,
living up to your potential, having the best life that you’re capable of.”

When Playing Devil’s Advocate, therapists draw group members into arguing
the position that it is imperative for them to stop binge eating (and purging) in
order to live the quality of life clients most desire. The therapists remain skeptical,
continuing to wonder aloud whether clients might indeed be able to continue binge
eating (and purging) while simultaneously living a fully satisfying life. The key to
this strategy’s success is polarizing the argument by describing clearly and reiter—
ating as needed what is meant by a high quality of life. If this is done, most clients
readily argue that their binge eating (and purging) is destroying any possibility of
their having a high quality of life.

When the therapists are convinced that the group is strongly in agreement,
they might summarize:

“Based on what we have heard from you, we’re convinced that there is abso—
lutely no other choice than to stop binge eating [and purging] and to get control
over any other problem eating behaviors. So, let’s face that reality and put it on
the table before we move ahead. Binge eating [and purging] is over. Whenever
you had your last binge [and/or purge], that was it—the last one. You simply
can’t have the life you want and continue this kind of eating. If you stop all
these problem eating behaviors, you have a shot at the life you want to lead.
But if you continue, you simply don’t have a chance. So the only choice you’ve
got is to stop binge eating [and purging]. Are we truly agreed?”