Dialectical Behavior Therapy for Binge Eating and Bulimia (24 page)

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
ment. After wholehearted effort, they can decide at the end of treatment whether or
not Mindfulness is useful. Two common questions and possible responses are:
••
Example 1: “What is the difference between Mindfulness and meditation, or
between Mindfulness and hypnosis?”

••
Potential therapist reply: “Marsha Linehan, who developed dialectical behavior therapy, translated the skills of meditation into behavioral terms. Meditation
is often associated with religious connotations, such as meditation as part of Bud—
dhism. Meditation
is a broader term than
Mindfulness, and it encompasses a variety
of practices for developing your mind in a particular way (e.g., concentration meditation, loving kindness meditation, mindfulness meditation). One purpose might
be to develop mindfulness, but people meditate for other reasons as well, such as
to develop compassion. Dialectical behavior therapy does not teach meditation. It
lays out the concepts and ideas of mindfulness to help you develop your mind to
be more aware, clearer seeing, able to access the here and now without judgment,
and so forth. In terms of mindfulness versus hypnosis—hypnosis involves focusing
awareness, whereas Mindfulness can be either focusing awareness or being aware
of multiple events at once.”

••
Example 2: “I’ve found using a mantra helpful when I practice diaphrag—
matic breathing rather than just being aware of my breath.”

••
Potential therapist reply: “Some people do notice that focusing the mind on
a particular word (e.g., breathe) or counting (e.g., from 1 to 10 and then repeating)
really helps. It may provide an anchor that helps you become more easily aware of
the fact that your mind has wandered.”

MINDFULNESS VERSUS BINGE EATING

DISCUSSION
P
OINT: “Now that we’ve introduced Mindfulness, do you think you could
be Mindful—attending fully to the present moment—and binge (and purge) at the
same time?”

By defnition, binge eating involves a loss of control over what one is doing or
a lack of awareness about what is going on. Binge eating is frequently a maladap—
tive means of escaping awareness or blunting experience by not thinking or paying
attention to one’s emotions or to one’s actions. It is an attempt to try to control,
change, or get rid of emotions. Mindfulness, on the other hand, is about increasing
awareness. Therefore, clients cannot practice Mindfulness and
binge eat. They are
opposite activities. Mindfulness and binge eating are incompatible in the same
way that clients cannot be both tense and relaxed. Clients would need to abandon
Mindfulness in order to binge eat.

A person cultivates Mindfulness, or the mind’s ability to know what is hap—
pening, in order to be aware of his or her experience and how his or her mental
activities are infuencing that experience. For example, usually automatic commentary accompanies a person’s experience, and it is frequently evaluative or judgmental. Mindfulness is also being aware of the commentary as just that, com-

Mindfulness Core Skills

mentary and not fact. For example, imagine watching a sports game on television
with the volume turned up versus with the sound turned off (i.e., with or without
the announcer providing minute-by-minute commentary). The experience would
be quite different. Without the commentary, you would simply see just that there
is a ball, there is someone who is picking up the ball, and so forth. Compare that
with watching the game with all of the excitement and stimulation provided by
the commentary in the background. The commentary obviously infuences your
experience. As another example, you could notice or be mindful of feeling sad and
notice the sadness arise and pass away without adding commentary. On the other
hand, you could feel sad and add the commentary that “I don’t have a good enough
reason to feel sad,” which might perhaps add guilt or shame to the experience.
Mindfulness is paying attention, noticing, and being aware of the sadness and,
if present the commentary; it means training the mind not to react to either one
but to remain aware of how the mind’s commentary or reactivity affects the fow
of experience. The point to emphasize is that, by practicing the core Mindfulness
skills, clients will be strengthening their ability to know what is happening and to
see how their own reactions or inner commentary infuences their experience. By
recognizing through the use of Mindfulness skills how this process works, one can
quiet down the inner commentary and associated emotion dysregulation. Clients
might want to experiment with “turning down the volume” to see how different the
experience is.

TROUBLESHOOTING
D
IFFICULTIES

IN
D
ISCUSSING
M
INDFULNESS
VERSUS
B
INGE
E
ATING

Therapists can expect a variety of reactions to the discussion of Mindfulness and
binge eating. Such questions and comments can be an opportunity to demonstrate
Mindfulness skills. That is, therapists can pay close attention to what is happening
and hypothesize about commentary that may be triggering emotional reactions.
Therapists can also ask clients to pay careful attention to what they are experienc—
ing and what “commentary” may have prompted the question.

••
Example: “So many Americans are overweight that it seems unlikely that
the whole country is out of touch with their emotions. Isn’t the problem in the environment?”

••
Potential therapist reply:
“I want to distinguish between being overweight
and binge eating. Not all people who are overweight are binge eaters, and not all
binge eaters are overweight. Binge eating is a problem in and of itself that involves
not only eating large quantities of food but also feeling a loss of control. The treat—
ment we are undertaking assumes that binge eating results in large part from
strong emotions and a defcit of adaptive skills or means to manage these emotions.
However, that is not to say that other factors, such as the environment, do not play
a role. The key for each of you is to practice and utilize Mindfulness skills to notice
and be aware of your own reactions to the environment and how these culminate
in binge eating. The same environment does not trigger binge eating in everyone.
Developing Mindfulness skills will strengthen your awareness as to how the envi-

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

ronment, your emotions, your thoughts, and your behavior lead to binge eating and
how to use Mindfulness skills to observe that whole process without reacting with
a binge. The treatment model we use to understand binge eating would not neces—
sarily apply to people who are overweight but are not binge eaters.”

THE THREE STATES OF MIND:
REASONABLE MIND, EMOTION MIND, AND WISE MIND

The next step in teaching Mindfulness skills is to initiate a discussion about vari—
ous states of mind. Therapists might ask clients to identify a positive and a nega—
tive state of mind and describe the thinking and behaviors that accompany each.
The main point to emphasize in this discussion is how one’s state of mind infu—
ences one’s thinking about others, one’s view of self, one’s behaviors, and so forth.
Explain that for the purposes of this treatment, three primary states of mind are
identifed: Reasonable Mind, Emotion Mind, and Wise Mind. Reasonable Mind is a
state of mind in which behaviors are controlled primarily by rationality, whereas
Emotion Mind is a state of mind governed primarily by emotions. Wise Mind is
the embodiment of Mindfulness skills and synthesizes both Reasonable Mind and
Emotion Mind. Yet Wise Mind is not simply adding Reasonable Mind and Emotion
Mind together. The quality of Wise Mind is different and is discussed later in this
module. Emphasize here that the skills taught in this treatment will enable clients
to become more aware of their mind states and to train them to move toward Wise
Mind, thereby fnding themselves able to make more effective decisions.

Reasonable Mind

Explain that Reasonable Mind is the state of mind in which rational thinking and
logic are dominant and therefore primary in determining how clients act. Reason
is often what is needed and what is effective for guiding behavior such as balanc—
ing checkbooks, solving logical problems, planning and evaluating, and so forth.
Reasonable Mind can be very benefcial, but if clients are using reason and logic
exclusively to inform behavior and decisions, they might end up overlooking impor—
tant aspects of a situation or of themselves. Strict reason may be limiting, like
monocular as opposed to binocular vision.

An example therapists might use to illustrate this point is that of choosing
between two jobs. Imagine that the frst job is much more geographically convenient and pays better. The second job pays less and isn’t as conveniently located,
but it’s the one the person is passionate about. Choosing a job based solely on rationality and logic might lead an individual to choose the more convenient and better
paying job. However, the person could end up being quite unhappy all day as he
or she works at a less satisfying, interesting, or meaningful job. In this scenario,
a decision based solely on Reasonable Mind could lead to a decision one regrets.
The skills will enable clients to build an awareness of their state of mind so that
they will know when they are operating exclusively from Reasonable Mind. Clients
would then have the opportunity to access Wise Mind, a state in which they might
fnd the perspective needed to take more effective actions.

Mindfulness Core Skills

DISCUSSION
P
OINT: “Can you think of examples when Reasonable Mind led to certain
decisions? Consider times when such thinking led to benefcial outcomes and when it
led to regret.”

Emotion Mind

The other end of the continuum is Emotion Mind. Therapists explain this as the
state of mind in which thinking and behavior are governed primarily by the cur—
rent emotional state, not on the basis of reason. Thinking is hot and emotional
rather than cool and rational. “Emotions are regulating you instead of you regulating your emotions.” In other words, behaviors such as binge eating (and purging)
and other problem behaviors are tightly linked to one’s emotions and occur seem—
ingly automatically. By defnition, binge eating (and purging) would not occur in
Reasonable Mind, in which behavior is based on logic, nor in Wise Mind, in which
one is aware and responding on the basis of inner wisdom. When clients are in
Emotion Mind and want to act effectively, practicing Mindfulness skills can help
them to access Wise Mind and not binge eat (and purge).

Make clear that therapists are not asserting that Emotion Mind does not have
a very important place in life. Emotions are powerful motivators of behavior. Clients have only to think of all the accomplishments in the world that were driven by
great love or passion. Emotions also provide an invaluable source of information.
But when clients’ emotions are very hot and intense, the resulting behaviors can
be out of touch with clients’ core values, such as when they turn to binge eating
(and purging). This can set up a cycle in which the problem eating behaviors lead
to shame, which, in turn, makes clients more vulnerable to Emotion Mind. Sleep
deprivation, stress, illness, and the infuence of substances such as alcohol are
other examples of things that can increase vulnerability to Emotion Mind, making
it more likely that clients would engage in binge eating (and purging).

DISCUSSION
P
OINT: “Think of times in your life when only your Emotion Mind was
operating. Were there times when this led to behaviors that were helpful to you? Were
there times when being governed by your Emotion Mind led to behaviors you regretted? What
are some of the factors that make you especially vulnerable to Emotion Mind?”