Dialectical Behavior Therapy for Binge Eating and Bulimia (26 page)

ExPERIENTIAL
Ex
ERCISE:
OBSERVE

“Put both feet on the foor. Place your awareness on your feet and just observe the
experience of your feet on the foor. It’s stepping back from an experience without
words. You aren’t describing the experience of your feet on the foor; you are just
placing your attention there. You can notice the experience without anything else,
without words or judgment. Just observe. It’s a bare-bones awareness. Now place
your awareness on the muscles in your neck and shoulders. Just observe the experience, the sensation in your neck and shoulders, without words. Just let your attention be there—stepping back from the experience, just being aware of it.”

Observing means allowing oneself to experience awareness in the moment,
whatever
is happening. Observing an experience does not mean trying to change
it, to put words on it, nor to terminate it. When clients are practicing Observe, they
are stepping back, letting their experiences be there. They are holding their experiences but not adding anything more.

Therapists inform clients that this observing stance may be applied toward
emotional experiencing. For example, if a client wants to practice observing sadness, this would mean allowing the sadness to be there as part of the moment
without trying to change it, make it different, or run from it. Clients may practice
observing with any emotion, whether it be anger, anxiety, joy, or other. If clients do

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

not know what emotion it is they are observing, they might try to observe accompa—
nying physical sensations, such as shallow breathing, clammy hands, a pounding
heart, or the sensation of one’s face reddening.

Observing requires the ability to step back and observe in a nonattached way.
It is important that clients understand that observing can be separated from the
response itself. Therapists describe how a person’s heart beating and observing
one’s heart beating are separate phenomena. The person’s heart is beating all the
time, whether he or she observes it or not. Observing
it beat is a different response
from the heart beating. Similarly, clients may observe their thinking, which is different from the response of thinking itself. Therapists underscore that this holds
true with emotions—clients can observe or watch emotions, which is different from
experiencing the emotions themselves. Indeed, clients may have many emotions
going on that they may or may not be aware of, emotions that they are not really
observing.

Therapists might use the helpful analogy of how observing is similar to being
in the eye of a hurricane, with the client’s life unfolding and emotions potentially
“swirling” all around. With Observe, there is a calm center into which clients can
step back to watch and maintain awareness of what is swirling around without
getting caught up in it. Clients do not get swept away but just Observe.

Suggest that clients begin practicing observing physical sensations before
moving to observing larger, more complicated phenomena, such as emotions. A way
for clients to strengthen their ability to Observe is to practice observing their feet
on the foor, hands on a table, the physical sensations of facial muscles, the sounds
surrounding them while sitting, and so forth.

Describe

Describe, the second “What” skill, involves using words to represent what it is that
clients observe. When practicing Describe, clients label a thought as a thought
(“I’m noticing the thought, ‘This is hard’”), a feeling as a feeling (“I’m experiencing the feeling of frustration”), and/or a sensation as a sensation (“My hands are
cold”). Therapists emphasize that when practicing Describe, clients are not adding
a judgment to the description (e.g., “It’s bad to have that thought or this emotion”).
Describe means not adding a moral dimension to one’s experience but just putting
words to the experience as it is.

Make sure that clients understand the potential difference between a thought
and a fact. For example, if a client notices the thought “ Two plus two equals four,”
his or her thought, in this case, is a fact. Too often clients aren’t thinking about
facts, yet they treat their thoughts as facts. For example, take the thought, “I’m no
good.” A client might treat this thought as if it were a fact. As therapists should
clarify, practicing the skill of Describe in this case would involve saying, “I just had
the thought ‘I’m no good.’” Therapists make sure clients appreciate the distinction
between labeling “I’m no good” as a thought and making the thought sound like a
fact by saying to oneself, “I’m no good.” The former involves being able to observe
what is going on in one’s mind and then describing it. Therapists may wish to use
the following script, modifying as needed, when introducing the conveyer belt exercise, an experiential exercise that involves the Observe and Describe skills.

Mindfulness Core Skills

ExPERIENTIAL
Ex
ERCISE:
OBSERVE
AND
D
ESCRIBE
WITH
A
“C
ONVEYER
B
ELT”

“First, sit in your chair with your feet on the foor, imagining a string from your
head to the ceiling, with your back similarly aligned. Find a place for your eyes to
look that won’t distract you. Here is an exercise that I fnd useful when I’m in a
situation that I can’t control—such as being stuck in traffc and feeling very anx—
ious about being late for a meeting. [Note: A self-disclosure involving the thera—
pist’s experience of actually practicing the skill to be taught is an effective way of
introducing it. Therapists should feel free to substitute a different self-disclosure
here.]

“I fnd this exercise very helpful to reduce my emotion’s intensity. You might
fnd it helpful when your emotions start getting intense and you’re feeling an urge
to engage in binge eating and/or purging. Take several deep breaths. ... Imagine
that your experience is on a conveyer belt. You can think of it as your stream of consciousness. Basically, your thoughts, your feelings, your sensations, your impulses,
your action urges—all of these are coming down a conveyer belt that is passing in
front of you. You are stepping back within yourself and just noticing, you are just
watching what is coming down the conveyer belt. First you observe and then you
describe, you put words on what you see. For example, ‘Here’s a memory, here’s a
tingling sensation, here’s a hollow sensation in my stomach, a feeling of guilt, an
urge to scratch an itch, an urge to eat. ...’ Just let it be whatever it is. You’re noticing without reacting. It’s just a moment-to-moment experience of describing, with
words, what you observe on the conveyer belt. Don’t try to stop the conveyer belt
should you notice something you particularly like on it or attempt to push things off
that you dislike. Just step back within yourself, observing and describing. ... Take
three deep diaphragmatic breaths before ending the exercise.”

Explain that Observe and Describe are very effective skills for clients to use
when they feel their Emotion Minds are getting ramped up. For example, if clients
feels themselves beginning to have an urge to binge eat and/or purge or engage
in other problematic eating behaviors, they can practice stepping back, taking a
breath, and simply observing their feet on the foor. Or clients may put their experience on the conveyer belt. Therapists point out that when clients observe and then
describe their experience with words, they are slowing that experience down. Wise
Mind can be used to help clients know when to move ahead.

Participate
Therapists introduce Participate, the last “What” skill, by explaining that this
skill involves entering fully into one’s experience, being fully aware, fully attend—
ing. When participating, clients are in their experience, having direct contact with
it, and letting go of self-consciousness. Therapists might suggest that clients imag—
ine the process of learning a dance step. At frst one would observe others doing
the sequence of steps. Then one would describe what is observed, such as “step to
the right, pause, step to the left.” Finally, once one knows the steps, the point is
reached at which one is immersed in the moment, becoming “one” with the activity.
The goal of the “What” skills is to be able to participate.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
TroubleshooTing DifficulTies
in Teaching The “WhaT” skills

••
Example 1: “I get so caught up in things that I can’t step back and detach
enough to Observe or Describe.”

••
Potential therapist reply: “What you would Observe and Describe would be
exactly that! For example, you might say, ‘I notice I’m getting caught up in my experience and having a hard time separating.’ That’s part of the experience. There’s no
way to do this ‘wrong,’ because it’s all your experience. What I think is happening
is that you’re judging as you Observe and Describe. So again, that’s part of the
experience. ‘I’m noticing the judgment. I’m not doing this right.’ Just put it all on
the conveyer belt.”

••
Example 2: “It’s easier for me to observe my feet on the foor without judging
than to observe other parts of my body, like my shoulders.”

••
Potential therapist reply: “To strengthen your skill with the essence of
Observe, practice observing things that are easier and less complicated frst. It
sounds like practicing observing your feet on the foor is the kind of exercise you
should be doing now so that you can build up your skill.”

••
Example 3: “I can’t seem to be able to observe without describing.”

••
Potential therapist reply: “Observing without describing is sensing. If you’re
describing at the same time as you observe, just notice the describing. Many people
have the same diffculty at frst. You’ll be able to separate them over time with
continued practice.”

••
Example 4: “It seems like with Observe and Wise Mind that I’m stepping
back from my emotion. Is there a time to just feel my emotions, or should I try not
to have my emotions because they might lead me to binge eat [and purge]?”

••
Potential therapist reply: “The idea is not to avoid emotions or emotional
experiences, but to be aware of them. In Emotion Mind, people often aren’t pay—
ing attention or aware of their emotions because they’re reacting to them. They’re
binge eating or doing other things to avoid feeling or to distract themselves in an
attempt to get rid of an emotion. So the goal is to be aware of your feelings without
reacting to them with actions or behaviors.”

••
Example 5: “It seems like a lot of the skills overlap.”

••
Potential therapist reply: “In a sense they do, or at least your practice of them
can. For example, you could start out practicing diaphragmatic breathing, then
practice Observe and Describe, and end up in Wise Mind.”

Mindful Eating

Mindful Eating, the next Mindfulness skill, is participating fully in each moment
with full awareness that one is eating. When clients eat mindfully, they are using
their “What” skills of Observe, Describe, and Participate. It is helpful to make
clear that, by defnition, participation involves Wise Mind and full awareness.
Binge eating may feel like participating because clients become very involved in
the act of eating. But binge eating by defnition is mindless because there is no
effective awareness of the consequences of one’s behavior. Nothing exists except the

Mindfulness Core Skills

food. Clients are on autopilot and are shutting down awareness. Like binge eating,
mindless eating also involves unawareness.

In our research studies, we have found it helpful to use an experiential exercise to teach Mindful Eating. Based on work by Kabat-Zinn (1990), we use raisins.
Therapists may wish to choose other foods for this exercise, either as substitutes
or in addition (e.g., chocolate chips). The following script may be useful, modifying
as needed.