Dialectical Behavior Therapy for Binge Eating and Bulimia (27 page)

ExPERIENTIAL
Ex
ERCISE:
MINDFUL
E
ATING

“For this exercise, we are practicing Mindfulness with a Mindful Eating exercise.
This particular exercise comes from a book called Full Catastrophe Living
by Jon
Kabat-Zinn [1990]. He has used Mindfulness as a basis for a stress-reduction pro—
gram he started at the University of Massachusetts Medical Center. These Mindfulness skills were found to be effective for reducing pain in individuals suffering
from chronic pain syndromes.

“Please take three raisins and hold them in your hand. Begin by observing
them in your palm, bringing your attention to each raisin. Observe each individual
raisin carefully, as if you had never seen a raisin before. You might imagine that
you’re like a Martian, seeing a raisin for the frst time. Really take the time to
observe. For example, notice the different shapes, surfaces, and colors. Notice the
texture with your fngers. While you are observing, be aware of any thoughts that
come into your mind about raisins or eating raisins. Now, bring just one raisin
to your nose and smell. Fully know what the smell of one raisin is like, have full
awareness of it. Now, with awareness of your arm and hand moving, place the raisin
in your mouth. Be aware of your mouth, your tongue. Then, very slowly, experience
the taste of one raisin by chewing it very slowly. Notice the texture on your tongue,
on the roof of your mouth. Notice how the raisin feels as you bite into it with your
teeth. Notice any impulses to swallow the raisin. Then, when you are ready, swallow it—following the taste as long as you can as it goes down your throat. Observe,
Describe, and Participate fully in the experience of eating just this one raisin.

“Eat each of the raisins in this way, chewing each one slowly, really tasting it,
noticing where the raisin is in your mouth, listening to the sounds of the chewing,
being fully aware. Notice whether there are any differences between the frst raisin
and the others. Does the taste change after you have already eaten one? Notice
your experience with each chew. You are mindfully eating—putting all your attention and awareness on this one thing you are doing. You are literally more awake,
rather than on the autopilot of mechanically eating without full awareness. When
you participate, you are attending to eating. So you really taste this one raisin. You
have the experience.”

Therapists emphasize that Mindful Eating involves all three of the “What”
skills. First, clients cannot describe something unless they frst observe it. Then,
while eating, clients are participating. Clients are not on autopilot or eating raisins
“hand to mouth.” They are eating with full awareness and attention to the experience of eating.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
DISCUSSION
P
OINT: “What was your experience? Is this how you normally eat things? If
not, how is it different? How can you use this experience to prevent binge eating (and
purging)?”

TROUBLESHOOTING
D
IFFICULTIES
IN
T
EACHING
M
INDFUL
E
ATING

••
Example: “It’s impossible to mindfully eat in our everyday lives the way we
ate the raisin.”

••
Potential therapist reply
: “It may not be possible to eat exactly the way we
practiced Mindful Eating all of the time. That exercise was meant to give you an
idea of how to practice the skill. A rehearsal for a play may not be exactly the same
experience as when you perform it. If you are with others at a restaurant, your
use of Mindful Eating would probably be different. But that doesn’t mean that the
breadbasket would be emptied without your noticing. You might eat a few bites
mindfully, then participate in the conversation, then eat a few more bites. It may
not be that you’re eating exactly the way you ate the raisins. But it would be a different experience, certainly, from eating mindlessly.”

SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to fll out the Mindfulness “What” Skills Homework Sheet (Appendix 4.5).

2.
Therapists instruct clients to practice Mindful Eating on at least three occa—
sions over the following week or until the next session, writing about their practice
on the “What” Skills Homework Sheet (Appendix 4.5).

ORIENTATION TO “HOW” SKILLS

Introduce the Mindfulness “How” skills as answering the question “How
do you
practice the ‘What’ skills of Observe, Describe, and Participate to access Wise
Mind?” These “How” skills include Nonjudgmentally, One-Mindfully, and Effec—
tively.

Nonjudgmentally

The frst “How” skill involves taking a nonjudgmental stance when Observing,
Describing, and Participating. In other words, this skill means that one is not
evaluating something or someone as good or bad, right or wrong, valuable or not,
worthwhile or worthless. The aim is to describe in terms of consequences. For
example, clients may Observe and Describe the consequences of binge eating (and
purging) in terms of the harmful effects on their self-esteem and physical health.
They may also Observe and Describe the fact that they want to change their prob-

Mindfulness Core Skills

lematic eating behaviors. Nonjudgmentally
means not adding the judgment that
one is a bad
person for binge eating (and purging) or a
good
person for not doing
so.

As therapists remind them, clients are not stopping binge eating (and purging)
for moral reasons. Clients are stopping because they’ve Observed
and
Described
that binge eating (and purging) is destructive—making them feel sick; wasting
time, energy, and money; and inevitably leading them to feel miserable. The point
here, therapists emphasize, is for clients to stop getting stuck in the good–bad,
right–wrong dichotomy of judging and, instead, to notice consequences.

Therapists might provide examples of common judgments: “I’m a failure,” “I’m
no good,” or “I’m stupid.” It is helpful for therapists to highlight how insidious
judgmental thinking can be. Many clients are often not even aware that they are
judging. Therapists underscore how judgments have a profound effect on emotions
and behavior. Therapists might suggest that when clients fnd themselves feeling
depressed “for no particular reason,” they may not be aware of how these emotions
were triggered by a bout of self-judging.

Therapists describe how practicing the skill of being Nonjudgmental involves
cultivating a nonjudgmental attitude toward one’s experience and what comes up
in one’s mind. Practicing Nonjudgmentally also means increasing awareness of
the amount of judging that takes place. Acknowledge that dropping judging is
diffcult, and make clear how important it is that, when clients become aware of a
tendency to judge, they not treat themselves judgmentally! Instead, the goal is to
simply Observe and Describe their judgments, not judge their judging. Remind clients of the conveyer belt exercise, in which clients may practice the Nonjudgmental
stance. For example, clients might notice a judgment coming down the conveyer
belt. At that point, clients can Observe and Describe its presence. Perhaps, espe—
cially if the judgments are frequent, clients might almost want to “wave” at the
judgment, acknowledging that “Yes, there’s that judgment about the shape of my
body again” or “Yes, there’s that judgment I have about the fact that I have an eating disorder in the frst place.”

Therapists illustrate the distinction between judging and noticing consequences by inviting clients to think about the different effect of saying “I am a bad
parent because I snapped at my child” versus saying “My snapping at my child hurt
his feelings, which I don’t want to do and would like to work to change.” The frst
sentence is a judgment, whereas the second one emphasizes the consequences.

DISCUSSION
P
OINT:

“Does the skill of Nonjudgmentally seem relevant to
you?”

Often judgments masquerade as facts. For example, the statement “I am overweight” may be a fact, but if the judgment “Being overweight is bad and overweight
people are less worthy than normal weight or thin people” is implied, then the judging piggybacks on the statement of fact and gets mistaken for part of the fact.

DISCUSSION
P
OINT: “Can you think of any examples of your judgments masquerading
as facts?”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Judgments are not preferences, values, or emotions. For example, the statement “I like jazz better than country music” is a preference, not a judgment. Judgments such as “this is better than this” can have their place in providing feedback
(e.g., grades) or information to a person about what to continue, change, or stop.
The problem is not so much with this type of judging that provides information.
The diffculty arises when the judgment is presented as a statement of fact, such
as saying that jazz is better
than country music.

Point out that negative self-judging is similar to self-invalidation. As we dis—
cussed during the description of the consequences of the invalidating environment,
many clients with a history of engaging in problematic eating behaviors have diffculty validating themselves. They seem to invalidate themselves automatically
or, in other words, mindlessly—without awareness. Self-invalidation and negative
self-judging can be thought of as stomping all over one’s experience, including feel—
ings, thoughts, and actions. For example, clients may or may not be aware of how
often they judge themselves as failures. Such a judgment, however, may be the trigger for an emotion such as despondency or depression. This may start them on the
path to binge eating (and purging) as a maladaptive means of escaping from the
negative emotions triggered by inner judging. Instead, observing the contents of
one’s mind, labeling a judgment as a judgment, and letting it go down the conveyer
belt brings awareness to the otherwise automatic link between self-judging and its
consequences.

DISCUSSION
P
OINT: “Take a moment and ask yourself how judging operates in your
life. Does it play a role in your internal chain of events leading to binge eating and/or
purging? How key a role do you think it plays?”

One-Mindfully

The second “How” skill, One-Mindfully, involves learning to control one’s attention.
With One-Mindfully, the mind focuses on just one thing at a time, one moment at
a time. Attention is not divided. Clients are fully present in just this one moment.
Impatience involves tapping one’s foot, wanting to get out of this present moment,
and wanting to move on. In contrast, when practicing patience, clients are letting
things be as they are in the moment, One-Mindfully. Thus, when thinking about
One-Mindfully, remember patience and letting go.

One-Mindfully brings the whole of one’s person to bear on the present activity, whether it be eating, driving, listening, or thinking about a problem, without
letting attention wander to something else. One-Mindfully also involves becoming
aware of when one’s mind wanders and controlling attention to bring it back to the
present moment and the present activity, no matter what it is.

For example, when clients are brushing their teeth, practicing One-Mindfully
means just brushing their teeth. One-Mindfully is related to concentration, being
able to stay focused. The idea is to try to stay in the moment, even if only for some
moments of one’s life. By anticipating the future or ruminating over the past, clients miss out on what is happening in the present, in this moment. Make the point
that life is only a series of moments.

Mindfulness Core Skills