Dialectical Behavior Therapy for Binge Eating and Bulimia (18 page)

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Example 2: “I didn’t fll out my diary card this past week.”

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Potential therapist reply: “Did you practice any of the skills, even if you didn’t
circle them on your diary card?” Note that the key here is to distinguish clients
who practiced skills but did not record them from clients who did not practice at
all. Most clients have at least thought about the skills, and it can be valuable to
reinforce this as a means of shaping their behavior. Point out that the diary card
is just a way to remind clients to practice skills, and what they did is most important. Then, focus on what got in the way of recording the homework practice (see
Example 4).

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Example 3: The client did not fll out his or her diary card and/or chain
analysis and just binged (and/or purged).

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Potential therapist reply: “What do you think is getting in the way of your
doing your homework?” Conduct a mini-chain analysis with the client. If the client
seems to have diffculty identifying interfering factors, the therapist might ask:
“Was it a week from hell? Was it that, at the end of the day, you wanted to forget
what you had eaten because you felt embarrassed, not wanting to look at yourself
and your behavior? These types of emotions are painful. But what you’re bringing
up is a very important issue. Your mood and your behavior are tightly linked. Once
fear of failure, shame, and embarrassment come in, they can block you from follow—
ing through on a commitment. How do you get yourself to do something, like practicing skills and flling out your homework sheets, that you don’t want to do? We
are assuming that you do indeed have some skillful behaviors that you can engage
in when you get really anxious, but turning to food is such a knee-jerk response
right now that it’s the frst thing off the shelf. It is crowding out your repertoire
of more effective behaviors. Can you recommit right now to really reach for these
other skills? And over this next week, can you practice imagining dealing with the
feelings and still doing the homework? Capitulating to the urge to avoid means
giving yourself up to binge eating [and purging]. Based on your experience, did
avoiding doing your homework work help you regulate the uncomfortable emotions
you describe?”

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Example 4: “I fnd it overwhelming. I can’t fgure out exactly what I’m feeling. I can’t write it down right.”

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Potential therapist reply: “Sounds like some capitulating and judging is going
on. I think I hear you saying that if you can’t get it perfect, you don’t want to do it at
all? (Client nods.) What’s great is that you have identifed some links that prevent
you from being skillful. It is so important not to give up. If something comes up that
is making you feel like you want to binge and/or purge but you don’t know exactly
what it is, that’s okay. You can still sit down with the sheets and fll out what you
can—even just one link or one of the boxes. It sounds like you got overwhelmed by
judging. Sometimes taking a break and focusing on breathing will reduce that so

The Pretreatment Stage

that it’s less intense. When you’re ready, go back to the diary card or chain and
work on one section at a time.”

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Example 5: “There wasn’t a prompting event—nothing was going on. I just
started eating.”

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Potential therapist reply: “Sometimes, when there’s no clear prompting event,
the issue is the buildup of vulnerability factors. Could that be the case here? What’s
the thing that if it hadn’t happened, you would not have binged? Why did you binge
on that day at that time and not at other times?”

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Example 6: “I can’t fgure out whether I had a binge or not.”

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Potential therapist reply: “This is something I can’t tell you—it is something
you have to fgure out for yourself. It may not be as clear-cut as you’d like, but it
depends on an inner experience. Were you out of control while eating? Remember
that having confict about whether to eat or what to eat—that ‘should I or shouldn’t
I’ feeling—those do not necessarily mean that you had a binge. Binge eating does
not depend on the type of food. Eating nonnutritious food does not necessarily con—
stitute a binge. A binge happens when you feel compelled and out of control, when
you can’t stop yourself once you start. It’s not the same as overeating, feeling as if
you were in control but feeling regretful that the amount of food was not consistent
with your goals to weigh less. If you determine that you’ve eaten with a sense of
loss of control, the issue is whether you had a very large amount of food or a smaller
amount of food. Don’t get too hung up on these details.”

Dialectical Abstinence

We recommend bringing up the concept of dialectical abstinence, originally devel—
oped in DBT for substance abuse (Linehan & Dimeff, 1997),6
in the second session with the client. It is useful to explain that bringing up this concept had been
planned
as part of the treatment protocol. In other words, therapists are not discussing it because any particular client reported having had a binge (and purge)
despite committing to abstinence. It is being brought up now because of its rele—
vance. There simply was not adequate time to review it during the initial session.

Clients coming to treatment are faced with a dilemma. Therapists might say:
“You have agreed that you value living up to your potential and feeling fully alive.
You recognize that continuing to use food is incompatible with achieving that life
and have made a 100% commitment to stopping binge eating [and purging]. The
dilemma is that what if, after making that commitment, you had or will have a
binge [or purge]?”

To deal effectively with that scenario, clients will be taught a very important
and useful concept called dialectical abstinence.

6Unlike the DBT for substance use disorders model (DBT–SUD), our DBT for BED or BN model does not
include the “touchdown every time” concept (e.g., the understanding that clients only are making the commitment for as long as they know with absolute certainty that they can keep it). In our model, the commitment is discussed as a powerful skill in and of itself, even if the client is uncertain about her or his ability
to keep it.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
“For years, there has been recognition of the existence of opposing forces. The
dialectical view is that for every force or position, there exists an opposing
force or position, a thesis and an antithesis. A good visual example would be
the positive and negative poles on a battery. They can exist side by side but
represent polar opposites. A dialectical view searches for a synthesis that is
more than the sum of the opposite parts. For example, the yin and yang sym—
bol is black and white, yet the synthesis of these is not merely the color gray. A
synthesis transcends both.”

The therapists explain that when individuals start to believe in or will see
only one
correct position,
one
way to do things, they tend to get into trouble. The
dialectical approach synthesizes the two positions by holding them together. The
dialectical approach recognizes that both exist and accepts this synthesis.

“So how does this relate to binge eating [and purging]? It seems very relevant
when you understand that we have two opposing forces operating that need to
be recognized and reconciled. On the one hand, you have set a goal for yourself
to stop binge eating [and purging]. You made a verbal commitment because
the reality of the situation is that feeling fully alive and good about yourself is
incompatible with binge eating [and purging]. Because the urge to binge [and
purge] is so strong, one must have this 100% strong commitment. Anything
short would be failure. When faced with the urge to binge [and purge], you
cannot have the idea that it is ‘OK’ to binge [and purge] and fail and to ‘just
try again.’ Such thinking is undermining and will make it more likely that you
will decide to binge eat [and purge].”

On the opposite side, it is clear that in not anticipating and preparing for a
slip, clients will be less likely to handle such an event effectively, should it occur.
“This is the problem we as therapists and you as group members are faced with.
How can one deal with these two opposing forces of success and failure? How do
you hold onto the goal despite not meeting it? What do we do?” Therapists present
the metaphor of the Olympic athlete as a helpful way for clients to think about this,
making the following points:

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“Stopping binge eating [and purging] is as big as any major Olympic event.
So imagine that you are like Olympic athletes and we, the therapists, are your
coaches. For Olympic athletes, absolutely nothing is discussed before the race except
winning or ‘going for the gold.’ If Olympic athletes thought or said that winning a
bronze medal ‘would be just fne,’ then their training mentality, performance, and
push would all be affected. That Olympic athlete must also not think about falling
down in a race or about what would occur should he or she twist an ankle before
the race. Those types of thoughts must stay out of the mind, even though these are
possible outcomes, and the athlete must only strive for the gold.”

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“In other words, think of yourself as being Olympic athletes in the Stop Binge
Eating [and purging] Event. The only thing you can possibly allow yourselves to
think about and discuss is absolute and total abstinence.”

The Pretreatment Stage

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“However, using the dialectical view, you, as well as Olympic athletes, must
be prepared for the possibility of failure. The dialectical dilemma is that both suc—
cess and failure exist. The dialectical abstinence solution involves, on the one hand,
your 100% certainty that binge eating [and purging] is out of the question and your
100% confdence that you will never binge and/or purge again. However, simulta—
neously, you must keep in mind—way, way back in the very farthest part so that it
never interferes with your resolve—that if you do slip, you will deal with it effec—
tively by accepting it nonjudgmentally and picking yourself back up. This means
acknowledging, ‘OK, I had a binge [and purge].’ You must be able to be aware of the
problem and acknowledge it in order to change it. Use the chain analysis, analyze
what was going on, become a problem solver. Then recommit to 100% full abstinence, knowing that that was the last time, that you will never slip again.”

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“We’re saying that it is possible to do these two seemingly contradictory
things—commit to absolute abstinence from binge eating [and purging] and
accept
a binge [and purge] should such behavior occur. We are not talking about accepting a binge [and purge] before
you have one. Saying to yourself, in the back of your
mind, ‘Oh, I guess it is really OK if I go ahead and binge [and purge] because if I
do, I’ll just do a chain analysis and recommit,’ will undermine your commitment.
Instead, this awareness of the possibility of binge eating [and purging] must be
buried somewhere outside of your awareness. You’ll respond that way if it happens,
but as it will never happen, you don’t have to worry about it.”

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to practice the skill of dialectical abstinence every day,
reading over the homework sheet (Appendix 3.13) and flling it out before the next
session.

Diaphragmatic Breathing

Inform clients that this next skill, diaphragmatic breathing,7 will likely be one
of the most useful they will learn in this treatment program. Diaphragmatic
breathing is deceptively simple. Based on our experience in our research trials,
clients report it to be their number-one most frequently used skill. We hear time
and again how incredibly helpful clients fnd it in aiding them to break the chain
toward problem eating. For clients who have heard of diaphragmatic breathing or
have even practiced it through other modalities (e.g., playing an instrument, yoga),
this is an opportunity to strengthen their use of it.