Dialectical Behavior Therapy for Binge Eating and Bulimia (13 page)

The Pretreatment Stage

Getting Verbal Commitment to Abstinence from Binge Eating and/or Purging
The next step is obtaining each client’s verbal commitment to abstinence. The therapists explain this request as follows:
“One thing we believe would be helpful, according to our model, is for you to
make a commitment to stop binge eating [and purging]. The reason we say
this is that we know from the research that there is a power to making a
commitment that isn’t there when you simply say: ‘I’ll try.’ People who make a
commitment
to do something are more likely to follow through. So we’re asking
you to make a verbal commitment, to look deeply within yourselves and make
a decision to give up binge eating [and purging] as an ineffective way of coping
with emotional distress.”

Therapists then ask clients to take a moment to think over the discussion that
just took place, reminding them that it was they who convinced the therapists
about the incompatibility of binge eating (and purging) and living a high-quality
life: “This is not something we are telling you, this is something you know in a
deep way, based on your own experiences. Stay in touch with the high cost of binge
eating [and purging] and fnd a way to make a deep commitment to yourself and to
the treatment to give up this behavior.”

Therapists then address each client: “Can you say, ‘I commit to stop binge
eating [and purging]’?” Once all clients have made the commitment, take a 5-to
10-minute break between the frst and second hours of the group session.

TROUBLESHOOTING
D
IFFICULTIES

IN
O
BTAINING
A
V
ERBAL
C
OMMITMENT
TO
A
BSTINENCE

In our groups, clients have differing reactions to being asked to make a verbal commitment to binge abstinence. Most tend to fnd it fairly straightforward, but some
clients express a number of concerns and negative emotions (e.g., anxiety, anger).
The observed discomfort and distress often is shared by therapists, who likely
experience a pull to soften or lessen the commitment that is asked for. Given the
research to date on this treatment’s effectiveness is based on the protocol described
in this book, we strongly recommend that therapists push for the highest level of
commitment from clients that can be obtained. The following approaches should
prove useful.

••
Example 1: “I won’t be able to keep the commitment. It’s impossible. So I
can’t make this commitment.”

••
Potential therapist reply
: “Would it literally be impossible to keep the commitment? I mean, it would likely be very, very diffcult and scary—but are you
saying that you think there is no way for you to physically survive unless you con—
tinue binge eating [and purging] ?” If the client concedes that it actually would be
possible to survive while abstaining, therapists might add: “So, it sounds like you
agree it might actually be possible to stop bingeing [and purging], but you are very
certain that you would fail in the attempt. Therefore it feels easier to tell yourself

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
that stopping binge eating [and purging] is impossible. Because if you were to try
your best but fail, you would have to feel awful about yourself not only for having
binged [and/or purged] but also for failing in your attempt to stop. I can understand that kind of thinking. Yet we know from research on commitments that when
people don’t make a full commitment—when, right from the outset they say there’s
no hope—the likelihood of success is lower.”

Other optional therapist replies include: “Are you worried about binge eating [and
purging] in this moment, or are you worried about the future?”
Reassure the client
that therapists are not talking about anything but this one moment, reminding
them that, after all, life is only made up of a continuous set of present moments.
“Can you make a commitment to try your absolute hardest to never ever binge [and
purge] again in this one moment, right now?” (Foot-in-the-Door Technique; Line—
han, 1993a, pp. 288–289). If the client replies that he or she can make a commitment for this one moment, therapists can ask for a moment more, and so on.

••
Example 2: “Okay. I’ll commit to trying.”

••
Potential therapist reply: “We really appreciate your willingness to give this
a shot. But we also know from research, as well as from our experience with this
treatment, that when people say they’ll ‘try,’ they are leaving the door open, even
just a crack, for turning to binge eating when it gets really hard. In a sense ‘trying’
is saying 75% of me will be on board, but if it gets really bad, I’m going to go back
to binge eating. It’s actually in that 25% of the time that reminding yourself of your
absolute commitment to no
binge eating will make it much more likely that you will
make it through without food. So let’s really step back and try to understand what
is making it hard for you to 100% commit.”

(Note: If the client continues to insist on “trying” as being the best he or she can
do, the therapist may decide that this response can be shaped over time. Until that
point, the therapist—to be adherent to this treatment—must hold frm to the idea
that binge eating can
be stopped and that a 100% commitment can be made, even
if the commitment has to be made and renewed one moment at a time. Indeed, as
discussed, clients can be reminded that life is only a series of moments.)
••
Example 3: “I can’t commit because it would be a setup to binge [and
purge].”

••
Potential therapist reply: “You’re worried about committing—you think that
if you do, you’re setting yourself up. You’d commit here and then go straight out to
binge [and purge] after the group is over?” We have found it helpful to ask, “Is it
impossible to have a goal and at the same time not meet it? Does it make it wrong
to have the goal?”

(Note: This response illustrates the concept of dialectical abstinence, which is for—
mally introduced during the next session.)

••
Example 4: “This doesn’t feel right. I feel like I’m being forced to make this
commitment.”

The Pretreatment Stage

••
Potential therapist reply: “I’m so glad you spoke up! I’m sure others feel this
way. We cannot be clear enough that only you can decide whether or not you want
to make this commitment. It is absolutely your life and your choice. The benefts
of binge eating [and purging] may truly be greater for you than the negative consequences. If so, it would make sense that you wouldn’t be willing to commit to
giving them up. If need be, you’re willing to live with the consequences—the health
problems, the lowered self-esteem, not having the high quality of life we talked
about.” Therapists stay silent long enough for the client to digest this (highlighting
freedom to choose and absence of alternatives; Linehan 1993a, pp. 289–290).

••
Example 5: “Life would not
be so bad if I could just cut down on my binge eating [and purging]—if I could just do it less often or binge on vegetables.”

••
Potential therapist reply: “Well, you’re right that it would defnitely be a big
improvement if you binged [and/or purged] less often. But my understanding of a
high-quality life is that in order to feel fully alive, fully responsive to each moment
that life gives you, it’s not possible to simultaneously avoid life or numb yourself
with food. Choosing to do something so destructive to yourself, can you at the same
time live to your full potential?” Again, therapists stay silent and do not push.

••
Example 6: “I can’t imagine a life without binge eating [and purging]. I’m too
scared to make the commitment.”

••
Potential therapist reply: “Is it hard for you to imagine what a high quality of
life looks like, so you aren’t sure what you are striving for?” Many people with BED
or BN become so accustomed to a lowered quality of life that they begin to feel as if
nothing more is possible. Therapists can gently point out that they are asking the
client to envision having a life that may indeed seem impossible, one that may feel
as if it is too much for the client to want for him-or herself: “It is
scary, but I think
you can do it. I think you can let yourself want your life to be that good.”

Pros or Cons of Binge Eating
This next skill involves summarizing the pros-and-cons discussion that took place
prior to the verbal commitment. To strengthen the commitment that has just been
made and to remind clients of their personal reasons for making and upholding the
commitment to stop binge eating, therapists distribute 3″
× 5
″
index cards. They
instruct clients to list their fve worst consequences of binge eating (and purging)
on one side. On the other, clients should list the fve most positive consequences
of not binge eating (and purging). Clients may fnd it helpful to look at the white
board pros and cons generated from the group discussion to stimulate their think—
ing.

SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to practice the skill of committing to binge (and
purge) abstinence by slowing down, taking a few deep breaths, and fnding a soft
place for their eyes to focus. Clients should then practice recommitting in their
“heart of hearts” to no more binge eating (and purging). Therapists might add:

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
“Try to stay with that feeling, that frm commitment, and the strength and clarity
that accompanies it.”

2.
Therapists suggest that when clients experience even the slightest thought
or urge to binge (and purge), they should bring to mind the promise they made to
themselves, as well as imagining the therapists and the entire group saying, “We
are all rock solid behind you in this.”

3.
Therapists instruct clients to review their 3″
× 5
″
cards with the pros and
cons at least once a day, as well as at any time they experience urges to binge (and
purge). Therapists might suggest that clients make multiple copies of these cards
to allow easy and quick reference, keeping the cards in readily accessible locations
such as one’s wallet or purse.

Orientation to Treatment

Treatment Model, Assumptions, and Rationale
Therapists begin this next section by congratulating clients on having been able to
make, for themselves, the commitment to strive for a higher quality of life by stop—
ping binge eating. At this point, as therapists explain, greater detail will be given
about the treatment, including its underlying assumptions and the model, both of
which were briefy introduced in the pretreatment interview.

Present the essential treatment model, perhaps by saying:
“This is how we understand binge eating [and purging]. First, there is a trigger or prompting event. We don’t believe binge eating [and purging] occurs for
no reason, even though sometimes the trigger may not be easy to pinpoint.
Similarly, we don’t think binge eating is a habit that serves no purpose nor an
addiction you have no control over. We believe it is something that you have
learned to do and can unlearn. So, frst, something happens. We refer to this
as a prompting event.”

To help clients generate ideas about possible prompting events for them, the therapist may fnd it useful to offer some illustrations: “For example, one prompting
event might be looking at your closet in the morning and telling yourself that you
have nothing that fts. It could also be experiencing your clothes as tight during the
day.” For Marie, a college student, typical prompting events for binges were having
exams to study for or receiving a grade lower than she had hoped for. For Sarah,
the mother of two younger children, not having her husband home at night was a
frequent trigger.