Dialectical Behavior Therapy for Binge Eating and Bulimia (17 page)

Therapists may wish to remind clients (particularly during the early sessions) of the skills taught so far by writing them on the board as well.
Therapists can emphasize that, because each client has a limited period of
time, the therapists really hope clients will use it maximally.

Therapists might make the following points:

••
“We’d like to start out with your letting us know whether you had a binge
episode [and purge] or not during the prior week, followed by answering questions
regarding your skill practice. This week, for example, the skills from our frst session that you were to have practiced were the commitment, the 3″
× 5
″
card, and
flling out the diary card itself. If you had a question or diffculty with the homework, this would be the place to bring that up so we can help you.”

••
“If you didn’t practice the skills or did not fll out a diary card or chain
analysis, we would like to understand with you what got in the way. This is impor—
tant because, as you’ll remember from the goals of treatment, our top goal—even
before stopping binge eating [and purging]—is to not engage in therapy-interfer—
ing behavior. If you could do this on your own, you would have! In our experience,
clients who successfully used this program to stop binge eating [and purging] did
their homework and attended sessions.”

••
“After reporting on your diary card and your practice of skills, we’d like you
to report on your chain analysis. Please use the chain analysis as a guide.”

••
“First, did you complete it? If not, then what got in the way? Perhaps you
felt embarrassed about your eating and did not want to turn it in. This response to
your emotions could interfere with treatment.”

The Pretreatment Stage

••
“If you did complete it, the frst thing we want to know is what the problem
behavior was. This means learning to describe the problem in behavioral terms.
Please turn to the path to mindful eating form and, during your 5 minutes, discuss
the highest problem behavior that you wrote about during the week.”

••
“Then, we want you to focus on the key dysfunctional link or links. To clar—
ify, the key dysfunctional link is not the prompting event or the problem behavior.
The key dysfunctional link or links is a point at which you capitulated, where you
reached the point of no return. Remember, by describing this as a dysfunctional
link, we are not judging it. For example, you might identify boredom as a key
dysfunctional link in your chain toward a binge. Boredom in and of itself is not
dysfunctional. It may be that you need to experience the boredom and not binge.
We are calling it a dysfunctional link if your reaction to the link leads you to the
problem behavior. The idea is to substitute skills especially at that link so that you
don’t turn to binge eating [and purging].”

••
“Please identify for us the key dysfunctional link or links and what skills you
think you’d use next time. If you need help, please ask the group.”

Practicing Identifying the Key Dysfunctional Link on the Chain Analysis
Especially in the beginning stages of treatment, it may be diffcult for clients to
identify the key dysfunctional link or links. In such cases, it may be helpful to use
Appendix 3.12 to review typical examples of key dysfunctional links.

The therapists read through the frst example:

“In this case, the problem behavior is a ‘subjective’ binge because the amount of
food consumed, as opposed to an ‘objective’ binge, is not unusually large. The
person was walking in a shopping mall and passed a shop selling sweets and
confections. That’s the prompting event. Looking into the window, the person
sensed a physical craving and thought, ‘I can’t resist them. They’re too good.’
The emotions identifed were anxiety and desire. The person capitulated, experiencing those emotions of anxiety and desire as being too intense to tolerate.
This is the key dysfunctional link for that person. Those emotions are not in
and of themselves functional or dysfunctional. What is dysfunctional is turning
in a driven, out-of-control manner to food to numb yourself or avoid these emotions. In that individual’s scenario, we’d spend time in group looking at what
happened and what he or she could have done differently. For example, perhaps
he or she could have thought about his or her commitment when experiencing
the desire and anxiety. This would break the link to the problem behavior.”

Therapists might have group members take turns reading through the other
examples and discussing the identifed links, and so forth. It is important to encour—
age questions and comments to make sure clients understand the concepts being
discussed.

Revisiting the Chain Analysis in Greater Depth

After the brief introduction to the chain analysis and after clients have had the
opportunity to fll one out at home, therapists will want to review the chain analysis

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
in greater depth. The therapists underscore how crucial this tool is as a problem—
solving strategy for increasing the client’s awareness of his or her dysfunctional
eating behaviors by allowing detailed examination of the factors that led up to the
binge (and purge) and to other problem eating behaviors, as well as of the conse—
quences that followed.

The therapists might begin by reviewing basic information about the chain
analysis. Now that the client has attempted one, this information will make more
sense. Therapists refer to the fgure of the chain at the top of the frst page of the
chain analysis (Appendix 3.6) to emphasize that problem behaviors such as binge
eating (and purging) do not “just happen.”

Understandably, as discussed, clients have often engaged in such behaviors
so repeatedly that they may feel as if the behavior occurs instantaneously or auto—
matically. With the use of the chain analysis, clients will see more and more clearly
how their binge eating (and purging) is actually a learned behavior that can be
understood. Prompting events that occur in the environment trigger a set of feel—
ings, thoughts, and actions that lead to the problem eating behavior. The conse—
quences of the problem behavior are important to analyze, too, as they may make
it more likely that another binge (and purge) or other problem behavior will occur,
thus linking this chain to yet another.

The chain analysis allows clients to slow down the process, to “freeze frame”
each link one after the other, so that eventually they can break the chain by substi—
tuting more adaptive links than the behaviors they have used in the past.

Ideally, clients would complete the chain as soon as the idea of binge eating
and purging occurs or as soon as they notice urges. This would facilitate early iden—
tifcation of factors and might lead to actually breaking the chain. If the problem
behavior has already occurred, clients should complete the chain analysis as soon
as possible afterward.

In our research studies, we ask clients to fll out a minimum of one chain per
week for at least the frst 15 sessions. This amount of practice is necessary to give
clients suffcient understanding to continue using the tool by themselves once treatment ends. Even if the client does not engage in binge eating (and purging), he or
she should use the chain to address another target behavior, either one targeted in
the path to mindful eating (Appendix 3.2) or to a problem behavior that is unique
to him or her and associated with binge eating. If the client has had absolutely no
eating-related problem behaviors in a particular week, he or she might describe a
past binge (and/or purge) episode or a non-eating-related problem behavior.

After 15 weeks, clients may fll out chain analyses on an as-needed basis—
meaning only if an eating-related problem behavior takes place.

Therapists then review the process of flling out a chain analysis. In a group
format, given the complexity of chain analyses, we have found it most time effective
to have the group review the sample chain analysis (Appendix 3.6), to elicit one or
two client examples from the group to review in detail, or to have the therapists
present a typical scenario for the group to work through together. When delivering
treatment within 50-minute individual-format sessions, available time is usually
suffcient to review the client’s actual chain analysis. (Note: The Troubleshooting
section on pp.
63–65 offers examples of how to handle clients who do not attempt
to fll out a chain analysis.)

The Pretreatment Stage

For therapists wishing to present a typical scenario to the group, the following
has proved useful. Therapists might say: “Let’s all work on this scenario. You’ve
had a long day, go to a friend’s or family member’s dinner party, feel you ate too
much at the party, come home, and decide to binge [and purge]. Does that sound
like something you’ve experienced? Let’s break it down by going through the chain
analysis.”

Ask the group to identify the problem behavior (e.g., an objectively large binge
[and purge] while at home) and the vulnerability factors (e.g., fatigue after a long
day, possibly conficting feelings about attending the party). Then, lead the group
in a discussion regarding identifying the prompting event. The point to emphasize
is that there is no right or wrong answer. If a client believes that the event that
started him or her on the chain toward the binge (and purge) was the dinner party
with its array of tempting foods, then that was the prompting event for that par—
ticular client. Other clients might argue that this made them vulnerable but that
there was no movement toward binge eating until they were alone, later that night.
In that case, the prompting event was being home late at night after the party was
over.

Request that clients turn to the second page of the chain analysis (Appendix
3.6) and write down some of the links that would have been included in their own
chains, adding, “the smaller and more discrete the links, the better.” Typically,
clients write down cognitions (e.g., “I shouldn’t have eaten so much”), bodily sen—
sations (e.g., feeling uncomfortably full, muscle tension), emotions (e.g., loneliness
after the party is over, shame about how much was eaten, regret over something
that took place at the party). The therapists then call for ideas from clients about
what could have been done differently. Specifcally, what more adaptive skills could
have been used?

Now have clients look at the third page of the chain. Begin by asking about
the immediate and longer term consequences of turning to food to manage the
uncomfortable emotions. Clients might identify how the binge (and purge) allowed
them to distance themselves from the uncomfortable emotions in the short term
but in the longer term led them to feel miserable, defeated, and despondent. Ways
to reduce vulnerability may include calming down and taking time to center themselves prior to, during, and after the party—reminding themselves of their com—
mitment to building a truly high quality of life. Ways to prevent the problem event
from recurring might include avoiding the kitchen on returning home and going
straight to one’s bedroom to read, speak on the phone, and/or fll out one’s diary
card and chain analysis.

troubleSHooting difficultieS

in reviewing clientS’ rePortS
of Skill
S
Practice

••
Example 1: The client has completed his or her chain analysis but tends to
have great diffculty focusing, during the allotted time of the group session, on
identifying the key dysfunctional link.

••
Potential therapist reply: Note that it is important to distinguish for clients

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
the differences between “telling a story” and reporting from the chain. When story—
telling occurs, the therapist should aid the client in focusing on the relevant ele—
ments. This can typically be done by saying: “Remember, the key dysfunctional
link is the one that you feel is most strongly linked to your problem eating behavior.
There is no right or wrong answer. Why don’t you turn to page two of your chain
analysis and read aloud what you wrote down?”