Dialectical Behavior Therapy for Binge Eating and Bulimia (16 page)

Review the commitment to practice the skills taught and to abstain from binge
eating (and purging). In a research setting, in which completion of research assessments is required and is included in a treatment agreement, therapists explain
that cooperation with such assessments is essential for evaluating the current
treatment program to create therapies that are as effective as possible.

After reviewing the group agreements, the therapists might ask, “Now that
you’ve reviewed these, do you feel you can sign them? If so, sign them and turn them
in.” After collecting the group agreements, the therapists should read through the
therapist agreements (several of which have been referred to in the preceding discussion). In our research groups, both cotherapists sign these agreements ahead of

The Pretreatment Stage

57

the session so that copies can be made. Before handing them out, therapists might
say: “Just as you are working very hard, we are equally committed to working very
hard to help you achieve your goal of stopping binge eating [and purging]. These
are our agreements. We have signed them and are giving you copies.”

Hand out a Sample Chain Analysis and Guidelines for Filling Out a Behavioral
Chain Analysis of a Problem Behavior (Appendices 3.6 and 3.7), if not already
included in each client’s binder. Blank copies of the chain analysis (Appendix 3.8)
are handed out as well. Therapists introduce the chain analysis as an invaluable
tool. Though it requires time and effort to fll out, it provides essential detail for
understanding the events that lead up to binge eating (and purging). Clients will
be asked to fll one out for the next session (with guidance from the sample chain
and the instructions). Once they have had some experience with it, clients will
have the opportunity to have more questions answered. (For further discussion of
chain analysis, see pp.
61–63.)

The purpose of a behavioral analysis is to fgure out what the problem (e.g.,
binge eating and purging) is, what triggers it, what its function is, what is interfering with the resolution of the problem, and what aids are available to help solve
the problem. Many errors in treatment of eating disorders are made because the
problem at hand is not fully understood and assessed.

Clients are referred to the top of the frst page of the sample chain analysis,
the diagram of a chain. The main point to make is that binge eating and purging,
like any behavior, can be understood as being made up of a series of components
or links. These links are chained together. As the therapists describe, behaviors
that are well rehearsed, such as binge eating (and purging), are often experienced
as occurring “lightning fast.” Clients often have great diffculty describing how
they got from Point A, at which they were not binge eating (and purging), to Point
B, at which they were. It feels out of control and can have a “blurry” quality. The
importance of using the chain analysis is to break down what seems lightning
fast into an understandable sequence of events. Emphasize that binge eating and
purging are learned
behaviors and thus can be
unlearned. The pattern linking the
components together can
be identifed. Furthermore, by breaking any of the links,
the chain to binge eating and purging can
be broken.

The chain analysis worksheet asks clients to identify what exactly the problem
behavior was, what the vulnerabilities were that made them more likely to engage
in it, what the prompting event was that triggered things, what the specifc links
were, and what consequences resulted.

The frst step is identifying the problem behavior. Therapists explain that clients should refer to the path to mindful eating (Appendix 3.2) and analyze the
highest target behavior that occurred between sessions. It is most important to
target any behavior that interferes with treatment. In other words, if clients are
not practicing the skills, they should write a chain on that problem behavior. Next,
binge episodes and/or purges would be targeted, followed by mindless eating, and
so forth.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
The chain analysis worksheet then asks clients to identify the prompting
event. Therapists explain that this is something occurring in the environment
that started the chain of events off. The third box on the work sheet focuses
on identifcation of vulnerability factors. Vulnerability factors occur before the
prompting event and include those factors that make the client more susceptible
to the prompting event, such as internal issues (e.g., an illness, being fatigued)
or external features (e.g., having no one else at home, facing tempting foods at a
buffet or party).

Next, clients are asked to imagine that the problem behavior is chained to
the prompting event. Therapists remind them that prompting events are external
to the client. Following that, what were the links, the specifc thoughts, actions,
bodily sensations, or events that took place? Once these are identifed, clients are
to describe what followed them. After describing the links, clients are to try to
think of what they could have done differently at each link to break the chain. In
particular, clients are asked to identify what skills could have been used—such as
referring to the 3″
× 5
″
card or renewing their commitment to stop binge eating
(and purging).

The last page asks clients to identify the consequences of the binge (and purge),
ways to reduce their vulnerability, things they could do to prevent the prompting
event from happening again, and questions about the harm that was caused. In
addition, when the client feels harm has been caused by the binge eating (and
purging) and experiences guilt and remorse, he or she may also consider what
could be done to repair the damage to themselves and others, if applicable.5

The therapist should emphasize the following:

••
Clients should not get “hung up” on trying to fll out the chain perfectly
or
getting it exactly
right. The most important thing is that clients begin to actually
use the chain. The sample chain and instructions for flling it out can serve as
guides. Greater detail is provided in future sessions.

••
Key dysfunctional links: When flling out the list of links on the second page
of the chain, clients should try to focus on the key dysfunctional link(s)—the link
or links (e.g., a particular thought, feeling, event, or action) that seem most associ—
ated with hooking or chaining together the prompting event (i.e., an external event
or cue triggering the chain) with the problem behavior. The therapist should make
clear that links may be functional or dysfunctional. It is how the client responds to
the link that may bring him or her closer to or farther from the problem behavior.

••
Clients will fnd, based on their experience with flling out chains over time,
how important it is to gain increased awareness of their thoughts and feelings—
something the invalidating environment discouraged.

••
At times, clients will have a lot to write in their chains. At other times,
less
so.

5In standard DBT, repairing harm is part of the egregious-behavior protocol and is used when clients
have caused harm to others (e.g., stealing). Binge-eating behaviors typically do not cause harm to others
so much as to the client him-or herself and are often accompanied by excessive guilt or remorse. In such
instances, correction and overcorrection may be helpful, and thus they are included in the standard form
for the chain analysis used in this treatment.

The Pretreatment Stage

59

SuggeSted
Homework Practice

Therapists instruct clients to fll out at least one chain analysis between sessions
so as to gain adequate practice with this essential tool. Clients may, of course, wish
to fll out additional chains.

If they are not already included in the client’s binder, the therapists hand out cop—
ies of the Diary Card and Instructions for Filling Out a Diary Card (Appendices
3.9 and 3.10) to each group member. The diary card’s primary purpose is to remind
clients to practice the skills during the week and to give them a place to record that
practice. It is also a space in which to keep track of targeted behaviors (e.g., binge
eating [and purging] and other behaviors on the path to mindful eating). Clients
are also asked to record their experience of different emotions (e.g., anger, sadness,
fear, happiness) each day and to notice patterns between those emotions and the
use of targeted behaviors. (Note: For clients with BED, modify the Diary Card by
omitting the “purge” columns and subdividing binge episodes into large [“objec—
tive”] and small [“subjective”] as described in Appendix 3.10. See also Wisniewski
et al.
[2007, p.
217].)

In addition, as emphasized, this treatment puts at the very top of the treatment hierarchy any behaviors that interfere with therapy. Therapists explain that,
therefore, clients are asked to rate their urges to quit therapy—both before and
after sessions—on the diary card. The therapists might mention that they will be
paying special attention to that rating.

In our research protocols, clients are asked to weigh themselves once a week
and record that weight on the diary card. Not weighing, as described, can be an
AIB for many clients. If clients report that weighing themselves has been a trigger
to binge eating (and purging) in the past, we suggest that they weigh themselves
right before a session. It is vital for clients not to avoid triggers, and this would
allow them to get support from the group for using skills to help tolerate the emotions experienced after stepping on the scale.

The reverse side of the diary card lists the adaptive emotion regulation skills
in the order taught in our research protocols. Clients are asked to circle the skill
on the day that they practiced it.

SuggeSted
Homework Practice

Therapists recommend that clients fll out their diary cards at least once a day.
These cards are reviewed at the beginning of each session.

(Note: As cannot be overemphasized, without practice, clients will not be suc—
cessful at changing a long-standing behavior such as binge eating and purging.
Ideally, clients will keep their diary cards with them during the day to facilitate
accurate records of skills practiced and use of the targeted behaviors. It is help-

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
ful to review the card at the end of the day to make sure that all the skills practiced and all targeted behaviors were recorded. For additional directions on flling
out the diary card, clients can refer to Instructions for Filling Out a Diary Card
[Appendix 3.10].)

Structuring the Client’s First Report of Skills Practice
As brought up in the introduction and Chapter 2, one of the distinctive features
of this adapted treatment as opposed to standard DBT is that the functions of
individual therapy and group skills training are brought together. Specifcally,
enhancing motivation (typically done in individual psychotherapy) and acquiring/
strengthening new skills (typically occurring within a skills training context) are
separated in standard DBT, whereas in DBT as adapted for binge eating (and
purging), these functions are combined into one session.

For therapists using a group format for treatment, the most challenging ele—
ment of therapy involves conducting this frst half of the treatment session, begin—
ning with Session 2. Following are some of the ideas we have found helpful:
••

••

••

On a white board (or handout), write general guidelines about how therapists would like clients to report on their skills practice during their allot—
ted time (e.g., 5 minutes). In our groups, we suggest that clients follow the
guidelines outlined in Appendix 3.11.