Dialectical Behavior Therapy for Binge Eating and Bulimia (19 page)

Begin by asking clients to refect on what happens physically when they experience very strong emotions. Often clients report that their breathing changes,
becoming dysregulated, and their heart rates speed up. Clients may also notice diz—
ziness. Point out that such physical sensations can increase feelings of distress and
7The method taught for diaphragmatic breathing is similar to that taught by Barlow and Craske (2006) in
Mastery of Your Anxiety and Panic
.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
cause clients to want to stop these feelings by turning to binge eating (and purg—
ing). Deep breathing interrupts this physical process and can reduce emotional
distress. Furthermore, deep breathing can facilitate mindfulness, a state of mind
that will be discussed in the Mindfulness module. One purpose of mindfulness is
to strengthen clients’ ability to focus attention and increase their awareness of the
present moment. Maintaining attention on a particular focus, such as the breath,
is one means of practicing mindfulness. The purpose of this focus is to bring the
attention back to the “here and now,” using a focus on breath as the anchor.

Therapists might state:

“Learning and practicing deep breathing and focusing on your breath are very
helpful for relieving emotional distress and physical tensions that have built
up and may trigger your urges to binge [and purge]. Your breath is always
with you, so the skill of deep breathing is a readily available skill, always right
under your nose. When you feel an urge to binge [and purge], you can calm
yourself down and ride out the urge by breathing. In doing so, you are replac—
ing the problematic eating behavior and thoughts with deep breathing and a
focus on your breath.”

Therapists might fnd it helpful to use the following script, modifying as needed.

ExPERIENTIAL
Ex
ERCISE:

PRACTICE
OF
D
IAPHRAGMATIC
B
REATHING

“Put one hand on your abdomen and one on your chest. This isn’t about trying to do
anything fancy! Just notice your hand on your abdomen. Then breathe while hav—
ing your hand on your abdomen. Practice taking slow, regular, fowing breaths so
that the hand on your abdomen moves up and down and the hand on your chest is
still. [Note: Therapists may fnd it useful to demonstrate, for example: “If you want
to watch me, it is like this.”] Remember, you are just doing slow breathing. Focus on
the hand on your abdomen slowing moving up and down. Be patient. If you notice
you are not breathing from your diaphragm, try not to judge yourself. Just keep
your awareness on your breath, letting it fow in and out. Your mind will
wander,
but the more you practice the easier it will be to notice that and just bring your
mind back to your breath.

“Inhale and exhale through your nose. As you inhale, slowly count one, two,
three. As you exhale, silently say to yourself something such as, ‘Relax’ or ‘Calm
down.’ Do this while counting up to 10 and then start at 1 again. Try to keep your
awareness on your breath. If it’s helpful to think of it this way, the rate of breathing
is usually about 10–12 breaths per minute. That means taking about 3 seconds to
slowly inhale and 3 seconds to slowly exhale.

“You can use this skill when you have worries or anxiety or any time you notice
your emotions becoming more intense. Simply slow down and focus on your breath.
In addition to practicing this skill when you are feeling intense emotions, practice
it regularly when nothing is going on—so that you gain facility with the skill. The
more you practice using this skill, the more you’ll be aware of your mind and your
breath. The breath can serve as the anchor to the mind.”

The Pretreatment Stage

SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to practice diaphragmatic breathing twice a day
for about 3–5 minutes at a time—when the sole purpose is to practice. This is called
formal practice.

2.
In addition, therapists instruct clients to practice informally—such as when
they are driving, while at a party, while on the phone, while at work.

3.
Therapists should make clear that it is especially important for clients to
practice using this skill when noticing any urges to binge eat (and purge).

4.
Clients should mark their practice of this skill on their diary cards by cir—
cling “diaphragmatic breathing” each day they use it.

APPENDIX 3.1

Emotion Dysregulation Model of Problem Eating

Event

(internal or external)

Positive/negative
emotion and need
for emotion regulation

Deficits in
adaptive emotion
regulation skills

Low expectancy
for mood
regulation

Increased anxiety
and fear, emotion
overwhelm

Urgency to stop
emotion
escalation

Decreased self-esteem
and negative self-view;
increased guilt and shame

Overlearned, impulsive,
maladaptive mood-regulation
behavior

BINGE EATING

AND/OR

PURGING

Temporary decrease
in distress

Avoidance of adaptive
mood regulation

From Dialectical Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice
Y. Chen. Copyright 2009 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers
of this book for personal use only (see copyright page for details).

APPENDIX 3.2

Goals of Treatment, Goals of Skills Training,

and
Treatment
Targets

Treatment Goals: Stop problematic eating behaviors (e.g., binge eating, binge–purge episodes).
Goals of Skills Training: Learn and practice adaptive emotion regulation skills to replace
maladaptive binge eating and other problem eating behaviors.

Treatment Targets:

PATH TO MINDFUL EATING

1.
Stop any behavior that interferes with treatment.*

2.
Stop binge eating (and purging).

3.
Eliminate mindless eating.

4.
Decrease cravings, urges, preoccupation with food.

5.
Decrease capitulating—that is, closing off options to not binge eat (and purge).

6.
Decrease apparently irrelevant behaviors—for example, buying binge foods “for company.”

INCREASE SKILLFUL EMOTION REGULATION BEHAVIORS†
BY LEARNING AND PRACTICING:

MINDFULNESS SKILLS
EMOTION REGULATION SKILLS
DISTRESS TOLERANCE SKILLS

Following the path to mindful eating will naturally lead to healthy weight regulation and an
enhanced quality of life.

*This path to mindful eating hierarchy is based on the population of clients recruited for our research trials. Though
not explicitly delineated in this model, decreasing any life-threatening behaviors takes precedence over the other
targets, just as in standard DBT, if crises arise.

†Skillful emotion regulation behaviors include skills taught in all the standard DBT modules. The term “emotion
regulation skills” in this context is not meant to apply to only the Emotion Regulation Skills module.

Adapted from Linehan (1993b) and Telch (1997a). Copyright 1993 by The Guilford Press and copyright 1997
by Christy F. Telch. Adapted with permission in Dialectical Behavior Therapy for Binge Eating and Bulimia
by
Debra L. Safer, Christy F. Telch, and Eunice Y. Chen (2009). Permission to photocopy this appendix is granted to
purchasers of this book for personal use only (see copyright page for details).

APPENDIx
3.3

Group Member Treatment Agreements
1.
I agree that I will keep confdential the information discussed during group sessions, including
the names of other group members.

2.
I agree not to form private relationships with other group members outside of the group
sessions.

3.
I agree to arrive at sessions on time.

4.
I agree to attend sessions each week and to stay for the entire 2-hour session.

5.
I agree to call ahead of time if I will miss or be late for a session. If I miss a session, I agree to
come to the clinic to listen to the recorded (e.g., audiotaped or videotaped) session and to
complete the skills practice and share this practice during the homework review.

6.
I agree to practice the skills taught.

7.
I agree to do my absolute best to stop binge eating and to help other group members to stop
binge eating.

8.
I agree to complete the homework assignments and bring them with me to each session.

9.
[Note: If applicable] I agree to complete the research questionnaires and interviews that are
part of this treatment program.

Group member’s signature

Date

From Dialectical Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice
Y. Chen. Copyright 2009 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers
of this book for personal use only (see copyright page for details).

APPENDIx
3.4

Individual Client Treatment Agreements
1.
I agree to arrive at sessions on time.

2.
I agree to attend sessions each week and to stay for the entire 50-minute session.

3.
I agree to call ahead of time if I will miss or be late for a session.

4.
I agree to practice the skills taught.

5.
I agree to do my absolute best to stop binge eating and purging.

6.
I agree to complete the homework assignments and bring them with me to each session.

7.
[Note: If applicable] I agree to complete the research questionnaires and interviews that are
part of this treatment program.

Client’s signature

Date

From Dialectical Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice
Y. Chen. Copyright 2009 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers
of this book for personal use only (see copyright page for details).

APPENDIx
3.5

Therapist Treatment Agreements
1.
I agree that I will keep confdential the information discussed, including the [names of group
members] or [client’s name].

2.
[Note: If applicable] I agree not to form private relationships with other group members outside
of group sessions.

3.
I agree to arrive at sessions on time.

4.
I agree to attend sessions each week and to stay for the entire [2-hour] or [50-minute] session.

5.
I agree to inform the group if I will miss or be late for a session. [If applicable] If I miss a
session I agree to listen to the recorded (e.g., audiotaped or videotaped) session.

6.
I agree to practice the skills taught.

7.
I agree to do my absolute best to deliver the best treatment that I can to help [group members]

or [the client] stop binge eating [and purging].

Cotherapist’s signature
Date

[Cotherapist’s signature]

[Date]

From Dialectical Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice
Y. Chen. Copyright 2009 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers
of this book for personal use only (see copyright page for details).