Dialectical Behavior Therapy for Binge Eating and Bulimia (15 page)

Therapists might conclude this section by saying:

“The good news is that what was learned in the past can be unlearned. Although
we won’t be spending our time exploring the origins of the emotional experi—
ences you had in your childhood, we will be focusing on correcting the skill
defcits that may have resulted. Indeed, this therapy is in some ways the Emotions 101 course you may have never had. Our treatment program will help
you express your 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 with a destructive
solution. You will learn to replace your maladaptive responses with adaptive
skills for gaining emotional control.”

The Pretreatment Stage

Reviewing Goals of Treatment, Skills Training, Treatment Targets
The goals of treatment, though introduced in the pretreatment interview, are
reviewed again in these introductory sessions due to their importance in providing
a frm foundation for the remainder of the treatment.

We suggest handing out hole-punched copies of the handout (Appendix 3.2)
Goals of Treatment, Goals of Skills Training, and Treatment Targets (as modi—
fed for the therapists’ particular client population) and reviewing it in detail. For
example, therapists might say:
“Again, what is really important to you and is the reason you joined this program is that you want to stop binge eating [and purging]. So that is our over—
all goal. The basic premise of this treatment program is that by learning and
practicing adaptive and skillful ways to cope with emotions, you will be able
to 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.”

Then review the path to mindful eating, either by discussing each point in
turn or by asking clients to recall from the pretreatment interview what these
behaviors entail. In either case, therapists should elicit a general commitment as
to the importance of each before moving ahead.

TREATMENT-INTERFERING
B
EHAVIOR

As the therapist explained in the pretreatment interview, even more important
than getting clients to stop problem eating is to prioritize any behavior that inter—
feres with coming to treatment, learning the skills, or practicing them. Without
fully receiving the treatment, how will anything improve? Do clients agree to work
on solving any such problems if they come up?

STOPPING
B
INGE
E
ATING
(
AND
P
URGING)

As discussed, and as clients have already agreed, this is a “must” to gain a higher
quality of life.

The treatment then targets behaviors that are believed to set clients up to
binge eat (and purge), beginning with eliminating mindless eating.

ELIMINATING
M
INDLESS
E
ATING

Therapists review how this includes eating when clients are not paying atten—
tion. Have clients ever experienced having a bowl of snacks in front of them while
watching television, then noticing that all the snacks are gone without recalling
actually eating them all? How do they react in such situations? Often, such eating
leads to a binge (and purge). Mindless eating also includes eating chaotically (e.g.,
throughout an evening) and never planning a meal. Though it may not feel like a
loss of control, this type of eating can lead to binge eating (and purging).

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
DECREASING
G
ENERAL
P
REOCCUPATION
WITH
F
OOD, URGES,
AND CRAVINGS

Clients with eating disorders report thinking about food a great deal of the time—
fnding themselves preoccupied by it and experiencing food-related urges and
cravings. This program assumes that these behaviors set clients up to eventually
binge eat (and purge) and therefore must be targeted. Ruminating about food, for
instance, can be a way to distract oneself from upsetting emotions. Because these
behaviors do not teach clients to cope effectively with their emotions, the preoccupation can lead to binge eating (and purging).

DECREASING
C
APITULATING

Therapists might use this opportunity to remind clients that they always have a
choice about whether or not to binge eat (and purge). Although it may feel as if they
must
do it, the reality is that individuals do
not
die if they are not able to binge
(and purge). The mind-set one enters into, called capitulating, may seem passive,
but it is an active process. It involves actively closing off options, deciding to give
up and to surrender to eating. It is a willful shutdown. Capitulating is maladaptive
behavior that sets one up to binge (and purge), and it may be a behavior that clients
recognize they use more generally.

DECREASING
AIB
s

AIBs are behaviors that clients pretend or try to convince themselves do not set
them up for binge eating (and purging) despite knowing deep down that these
behaviors are risky. Examples include making the decision to go grocery shopping
when feeling particularly vulnerable to urges to overeat (but rationalizing that one
is “simply going to buy milk”) or buying bake sale items at a fundraiser (instead of
offering a donation). Ask clients to give examples from their lives.

To stop bingeing (and purging) and get control over their eating, clients will be
replacing their problem eating behaviors with adaptive skills for gaining emotional
control. These are taught over three modules.4

Mindfulness Skills.
These skills increase awareness and experience of the
current moment without self-consciousness or judgment. These are the core skills
of the treatment program.

Emotion Regulation Skills.
These skills include helping clients identify emotions, understand their function, reduce vulnerability to negative emotions, and
increase positive emotions. By understanding how emotions work, clients are
4As mentioned earlier in this chapter and in the Introduction, the treatment manual described is based on
using the three modules as presented. Decisions about the number of modules were based on the popula—
tion studied and research issues (e.g., omitting the Interpersonal Effectiveness module to limit theoreti—
cal overlap with IPT). Interpersonal issues are highly relevant with patients who have eating disorders.
Therapists may decide to add this module, but the decision to do so has not yet been the subject of empirical
testing within our research protocols with patients who have BED or BN.

The Pretreatment Stage

more able to regulate them. This may include reducing the intensity of an emotion
before it gets fully going, modifying the way the emotion expresses itself once it has
already started, and/or acting in ways that are “opposite” to the current emotion.

Distress Tolerance Skills.
These skills include Crisis Survival skills and accep—
tance skills to help clients tolerate distressing emotional states in situations that
cannot, in that moment, be changed.

It is expected that clients will learn and practice all the skills so that they can
fnd out which ones ultimately will work best for them.

Therapists might reinforce the fact that abstinence from binge eating (and
purging), according to research, leads to weight stabilization or weight loss (see
also earlier discussion and Chapter 2). In addition, if clients stop bingeing (and
purging), it is expected that their moods will improve, as should their self-esteem
and overall quality of life.

Orientation to Structure of Sessions

The structure of sessions is described to give clients a sense of the format of each
weekly session. Group sessions, per our research protocol, last 2 hours and include
8–12 clients. Depending on therapists’ clinic settings and client populations, groups
might be extended to 2½ hours. The frst half (50–60 minutes in our groups) is
devoted to reviewing the past week’s skills practice, diary card, and chain analyses—as will be described. After a 5-to 10-minute break, the second half of the
session is devoted to teaching specifc skills.

Sessions carried out in an individual format last 50–60 minutes. The same
session structure is maintained, with the frst 25–30 minutes used to review the
client’s prior week of skills practice (including review of the diary card, chain analysis, etc.), followed by teaching new skills for the remainder of the session.

Especially when sessions are carried out in a group format with 10 or so clients,
we fnd it necessary to structure the sharing to ensure that each group member
has a chance to speak (see also discussion in Chapter 2). We review this structure
in greater detail in subsequent sessions. The point for therapists to communicate
at this juncture is that each group member is expected to share his or her practice
of the skills each week during the frst half of group. In groups with 10 clients,
this means approximately 5 minutes per group member. Therapists emphasize
that structuring this frst half is needed given that this is a time-limited treatment program that focuses on skill acquisition and strengthening. Treatment is
not intended, as has been noted, to cover all aspects of clients’ lives or to handle
all crises. Current diffculties can be discussed insofar as they relate to the skills
being taught. The idea is that learning to use adaptive emotion regulation skills
will ultimately enhance clients’ ability to cope with all areas of their lives.

For clients to make maximal use of treatment, it is important for them to plan
ahead as to what they most want to discuss. Clients have the opportunity to review
their practice of the skills over the previous week (i.e., what worked out, what they
would like help with) and to report from their chain analysis, a tool that analyzes
the client’s engagement in problem behaviors over the prior week.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

Therapists remind clients of the dates of sessions scheduled during this course
of treatment. Although our research trials were based on a 20-session format, the
number of sessions may vary depending on differences in client settings and treatment populations.

Group Member and Therapist Treatment Agreements

The Group Member and Therapist Treatment Agreements (Appendices 3.3 and
3.5), initially discussed during the pretreatment interview, are handed out and
reviewed in the introductory sessions. Therapists read each of the items on the
agreement aloud, emphasizing that these agreements are essential to provide opti—
mal conditions under which group members can receive beneft from the treatment.

As the therapists explain, confdentiality, or keeping information about what
group members say private, is vital to create a safe environment in which group
members feel free to openly discuss highly personal issues and feelings. Not forming private relationships with other group members that would interfere with the
vital ability of the group to function as a whole, such as forming exclusive cliques,
is also important. In turn, the therapists agree not to form private relationships
with clients that would be disruptive.

Therapists underscore the expectation that group members will prioritize this
experience and protect the group session time so that they can attend regularly.
Absences should be only those that are truly unavoidable, such as the case of seri—
ous illness or out-of-town trips that cannot be rescheduled. It is asked that group
members call the therapist (or a designated person) if they will miss a session so
that the group can be informed and not worry about the absent group member.
As described earlier, therapists may also call clients who are expected at group
but are not present at the start of the group session. The therapist takes this
opportunity to emphasize that clients are expected to complete homework each
week even if the session was missed. In our research trials, group sessions were
recorded, allowing missed sessions to be made up by having group members come
in to watch or listen to the videotape or audiotape. This held true, as we pointed
out in our research trials, for therapists as well. If a cotherapist missed a session,
he or she agreed to listen to the missed session before the next group meeting. If
a cotherapist has a planned absence, he or she agrees to inform the group of this
ahead of time.