Dialectical Behavior Therapy for Binge Eating and Bulimia (23 page)

On the one hand, you’ve made a 100% commitment to stop bingeing, and anything short would be a failure.
When faced with the urge to binge, you cannot have the idea that it is “OK” to binge and fail and to “just try
again.” Such thinking would undermine your goals and make it more likely that you will decide to binge eat.
On the other hand, you need to be prepared to deal with a binge effectively if it does occur. You can create
the synthesis by recognizing that both forces exist. In the forefront of your mind is your awareness of your
100% commitment and 100% certainty that binge eating is not an option. However, simultaneously, way, way
back in the very farthest part, so that it never interferes with your resolve, is the awareness that if you slip,
you will deal with it effectively by fguring out what happened, accepting it, not judging yourself, and picking
yourself back up and concentrating on what you have learned. Then you recommit to stopping bingeing,
back to the 100% knowledge that you will never slip again. The dialectical abstinence solution involves
holding the two opposite forces: 100% certainty that binge eating is out of the question and the resolve to
deal with it effectively if it happens.

A good mental picture is an Olympic athlete. When the athlete is training, nothing is discussed except
winning and going for the gold. If the Olympian athlete thought or said that winning a bronze medal would
be fne, then his or her training mentality and performance would be affected. The athlete is similar to you in
that you can focus only on absolute and total binge abstinence. Yet, of course, you must also be prepared
for the possibility of failure, and the key is to be prepared to fail well.

It is also useful to apply a dialectical view toward yourself. You have come into therapy to make a change
so that you can live the high-quality life that you want. At the same time, you must accept yourself just as
you are, in this moment. Otherwise, you put yourself into a state of self-criticism, self-loathing, and self—
aversion—a state in which it’s very easy to feel hopeless, to give up, and to experience urges to binge eat. A
dialectical view involves accepting exactly where you are, right at this moment. It doesn’t mean necessarily
approving of where you are or liking it. But it means accepting it the way you accept gravity. It simply is your
reality at this moment. The synthesis is that in accepting yourself exactly as you are in this moment, you
are doing something you most likely have never been able to do. Accepting yourself as you are, without
judgment, means you have already begun to change.

Instructions for Practicing Dialectical Abstinence

Practice allowing yourself to know that success and failure can exist simultaneously. Make a 100%
commitment to stop binge eating
and also reserve in the back of your mind that if you slip you’ll deal with it
effectively. Keep one in the forefront of your mind and the other far back, so far back that it doesn’t interfere
with your resolve. If you do slip, practice accepting the slip, not judging yourself, picking yourself up again,
and recommitting to your 100% resolve to never binge again. Remember, commitment is an active process.
It involves continual awareness and recommitment. Write about your practice of this skill in the following
space (or reverse side).

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).

CHAPTER
4

Mindfulness Core Skills

M
indfulness skills are taught at the beginning of treatment because they are
the basic or core skills that clients need to learn in order to successfully utilize the
other skills taught over the course of treatment. Mindfulness skills form the foundation on which the other skills are built. That is, when clients are frmly rooted
in Mindfulness, they can see more clearly what constitutes skillful behavior and,
therefore, which skills to use. In its broadest sense, mindfulness is simply keeping
something in mind (e.g., the breath) or being aware or noticing what is happening
(e.g., being tired). This ability to keep something in mind, to notice or be aware, is
fundamental to deciding what skillful action to take. Therefore, Mindfulness skills
are the foundation on which clients must stand to skillfully regulate emotions. All
human beings possess the ability to be mindful; all have the seed of mindfulness
within them. Most need to water the seed through daily Mindfulness practice, so
the seed can be strengthened and grow from a seed into a tree that provides shel—
ter.

The frst step in orienting clients to the Mindfulness skills (Appendix 4.1) is to
state unequivocally that these skills are essential, fundamental, and key to their
achieving their desired goals of stopping binge eating (and purging) and experienc—
ing a happier, less stressful quality of life. That is, therapists must convincingly
sell clients on the fundamental nature of Mindfulness skills and link them to stopping binge eating (and purging), as well as to improving the client’s quality of life.
The importance of emphasizing Mindfulness skills cannot be overstated. Clients
may assume that mindfulness is some abstract concept that they cannot possibly
learn or practice. Therapists must reassure clients that mindfulness, or paying
attention in a particular way, is a skill everyone can develop. A brief review of the
DBT emotion regulation model of problem eating (Chapter 3, Appendix 3.1) may
facilitate making links between learning the Mindfulness skills, emotion regulation, and stopping binge eating (and purging). This model conceptualizes binge
eating, purging, mindless eating, preoccupations with food, and all other problem
eating behaviors as attempts to cope with emotions that feel out of control and

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

overwhelming. The link between emotions and behavior becomes so overlearned
that clients are frequently unaware of the emotions that trigger their maladap—
tive eating patterns. Turning to food in response to emotion dysregulation often
feels automatic, like a knee-jerk reaction. This is where the mindfulness skills ft
in. These are awareness skills that empower clients to break the automatic link
between emotions and problem eating, for example, by noticing that feeling dis—
couraged leads to the urge to binge.

Mindfulness skills enable clients to experience emotions as arising and pass—
ing away rather than reacting emotionally by binge eating (and purging). Mindfulness skills teach clients to experience emotions without judging them or reacting
to them in a manner that ends up backfring and creating more pain and suffering.
Though clients will be taught other modules, they will continue to practice Mindfulness throughout the treatment and, hopefully, for the rest of their lives. These
skills form the bedrock supporting clients in learning to master mental processes
(e.g., attention) that facilitate adaptive emotion regulation rather than experienc—
ing their minds as beyond their own control. When introducing Mindfulness skills,
therapists will want to emphasize both that these skills take time, patience, and
practice to learn and will not offer an “instant fx” and
that clients
can
learn these
skills and receive some beneft even at the beginning of practice. It will not be
magic and instantly solve all problems, but practicing Mindfulness will help by
building an adaptive skill and weakening the habit of binge eating. As with any—
thing worth having, to get something out of these skills requires an investment.
Successfully developing Mindfulness will require the clients’ commitment, perse—
verance, intention, effort, and continued practice over their lifetimes.

Therapists might liken practicing Mindfulness skills to going to the gym. Reg—
ular practice is required to build muscle. The benefts of strong muscles, like those
of Mindfulness, transfer from the gym to many aspects of a client’s life. And if
clients stop going to the gym, muscles deteriorate. Like learning to ride a bicycle or
to dance salsa, practicing Mindfulness may feel awkward initially. But in the end,
clients should be able to access Mindfulness skills without effort—in the way that,
with lots of practice, one “becomes” the bicycle or “becomes” the dance.

DEFINITIONS OF MINDFULNESS

A good place to begin the discussion of Mindfulness is to provide clients with sev—
eral defnitions (see Marlatt, 1994, pp. 176–177). These defnitions can be read
aloud to the group while clients follow along on a printed copy that clients may also
review at home. To be mindful is to keep something in mind, to pay attention. For
example, if you are told “Be mindful of how you speak,” you are being asked to pay
attention, to be aware of what you are saying and how you are saying it. Similarly,
being mindful of one’s emotions involves keeping emotions in mind, being aware,
paying attention. Mindfulness is often defned as being nonjudgmental and “present moment.” In other words, the awareness or attention is nonjudgmental and
present oriented. It is important to underscore, as noted, that developing this type
of attention or awareness takes effort and practice.

Mindfulness Core Skills

Mindfulness is that quality of attention which notices without choosing, without
preference. It is a choice-less awareness that, like the sun, shines on all things
equally. (Goldstein & Kornfeld, 1987, p. 19)
So Mindfulness is simply noticing what is happening, what is arising and
passing away in one’s experience, without approving of some and rejecting other
experiences. When one is being Mindful, one is open to all emotions, just as the sun
does not choose who or what to shine on.

Mindfulness means seeing how things are, directly and immediately, seeing for
oneself that which is present and true. It has the quality of bringing our whole
heart and mind, our full attention to each moment. (Goldstein & Kornfeld, 1987,
p. 62)

Mindfulness is the mind’s ability to know what is happening here and now.
Emphasize that this knowing is a necessary step in making any change. Mindfulness gives one the space or freedom to “see” what is going on without rushing in to
stop, change, or “fx” the experience. Paying attention in this way permits one to
“gather the data” of experience and to use this full, mindful awareness as a basis
for making decisions about future behavior. Behavior then becomes more skillful,
less reactive.

Mindfulness accepts present experience as one of constant change. All experiences arise and pass away like waves on the sea and mindfulness accepts this on
a moment-to-moment basis. There is not an attempt to control or fx the present
moment or what happens next. (Marlatt, 1994, p. 177)
Many clients with problem eating behaviors spend much of their lives avoid—
ing emotions. Binge eating (and purging) is one method to block emotional awareness; however, emotions become stopped up instead of fowing in and passing away
like waves on the sea. Mindfulness, in contrast, involves paying attention to one’s
emotions, thoughts, physical experiences, and so forth without necessarily try—
ing to terminate or end them. Mindfulness is being open to whatever is happening, accepting and honoring what is happening because it is
what is happening. It
involves learning to be in control of one’s own mind by learning how to attend or
be aware of one’s experiences as fully as possible, learning to be in control of one’s
attention.

TROUBLESHOOTING
D
IFFICULTIES
IN
O
RIENTING
TO
M
INDFULNESS

Clients typically have questions or concerns about the practice of Mindfulness. It
is important to acknowledge whatever doubts or confusions are raised and address
them as best one can. Clients can also be reminded that this is an experiment they
can test out. Their task and commitment is to practice these skills during treat-