Dialectical Behavior Therapy for Binge Eating and Bulimia (34 page)

Balancing Eating

“Do you notice a link between your emotions and not eating properly—eating too
much, too little, or eating food with too little nutritive content (‘junk’ food)?” For
many clients, eating poorly can lead to feeling more grouchy and irritable. Balanced
eating requires awareness of the link between how one eats and one’s vulnerability
to negative emotions. “What patterns do you notice, whether in the short or long
run, that are associated with your having greater emotional vulnerability?”

Avoiding Mood-Altering Drugs

Therapists review with clients how certain substances (e.g., caffeine, alcohol) may
infuence a client’s mood. For instance, does caffeine cause the client’s body to be

Emotion Regulation Skills

more agitated, less calm? What is alcohol’s effect on their bodies? Is the client more
likely to binge (and purge), for example, after drinking alcohol? Does the client use
any other mood-altering drugs, and, if so, what is their relationship to the client’s
vulnerability to binge eating (and purging) and other problematic food behaviors?

Balancing Sleep

Therapists emphasize that sleep is essential for the client’s emotional stability.
When one is tired, one becomes more emotionally vulnerable and, therefore, more
susceptible to bingeing (and purging). Often clients will admit to using food to
increase their energy levels. “Do you try to mask fatigue with food rather than
responding to fatigue directly by taking a nap or getting more sleep? Is this work—
ing for you? If not, what changes might you be willing to make?”

Getting Exercise

For clients with a tendency to eat when feeling depressed, lack of exercise can be a
particular source of vulnerability. Increasing activity and physical stamina can be
an effective route to improving one’s mood, reducing stress levels, and increasing
one’s sense of well-being. Therapists remind clients that changing one’s behavior
can change one’s emotional experience. When depressed or discouraged, becom—
ing more active can help to shift one’s state of mind toward being less despondent.
Therapists explain that exercise is a mood-independent behavior in that it is not
tightly linked to one’s emotions. Indeed, exercise can act to change one’s mood and
reduce emotional vulnerability. Therapists convey clearly that getting moderate
exercise does not require running a marathon nor pushing oneself to the point of
injury. It means, in a balanced way, doing something to get one’s limbs moving,
such as a walk, swim, or bike ride. “Do you have a regular exercise program? What
has been your experience with exercise? Does exercise affect your mood, binge-eating patterns, and/or purging behaviors?”

Building Mastery

Therapists describe building mastery as performing activities that increase confdence and lead to a sense of competence. Feeling more satisfed and fulflled
decreases the client’s vulnerability to negative emotions such as depression. Therapists may need to work with the client to identify activities that require some
degree of effort, are somewhat challenging, and help the client to build self-esteem
and satisfaction. Therapists underscore that engaging in such activities each day is
key, because actually doing these confdence-enhancing endeavors (not just think—
ing about them) gives new and different feedback to the client’s brain, thereby
helping to change her or his emotional experience. Like exercise, building mastery
is a mood-independent behavior. It might involve doing something creative, such as
making jewelry. Especially for binge-eating clients who are overweight, exercising
is an excellent activity that helps to build mastery. “Can you think of activities that
would build mastery for you?”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to review the six domains for reducing their
vulnerability to Emotion Mind. Clients should make specifc plans to reduce their
vulnerability within each pertinent domain. For example, if too little sleep is a
problem, clients might make it a goal to get at least 8 hours’ sleep for 5 of the next
7 days.

2.
Clients should fll out their goals in the Reduced Vulnerability to Emotion
Mind section of the Steps for Reducing Painful Emotions Homework Sheet (Appen—
dix 5.6, adapted from the Emotion Regulation Homework Sheet 3 in Linehan,
1993b, p. 164). (An example of a completed homework sheet is provided in Figure
5.2.)

STEPS FOR INCREASING POSITIVE EMOTIONS

Therapists introduce the basic assumption that usually there are good reasons to
explain why individuals experience negative emotions such as unhappiness and
depression. One is that an imbalance exists between the number of negative experiences clients have in their lives compared with the number of positive experiences.
Another common reason is that clients do not focus attention on and fully experience the positive emotions they do have. Both of these are discussed in greater
detail in this section.

Increasing Daily Pleasant Experiences
Therapists check with clients regarding whether the assumption holds true for
them and, if so, whether this skewed ratio creates unhappiness. Perhaps clients
have even learned to expect negative experiences. If therapists obtain agreement,
they state explicitly that clients who wish to experience more happiness will have
to put considerable effort into creating more positive experiences. No one is very
happy when not engaging in activities that are positive, meaningful, fulflling, and
satisfying. Like saving pennies in a piggy bank, clients will have to accumulate or
invest in many positive experiences to reap rewards.

Emphasize the key role of balance when clients begin to think about creating
more happiness for themselves. Just as clients cannot work all day every single
day, they cannot lie out and relax on a beautiful beach all day every single day.
As therapists explain, experience with clients with eating disorders leads them to
assume that a client’s imbalance is usually one of having too few pleasant events,
which can then increase the likelihood of their turning to food as a way of coping
with overwhelming negative emotions.

Explain that the idea behind the Adult Pleasant Events Schedule (see Appen—
dix 5.7 for an abbreviated version of Linehan’s [1993b, pp. 157–159] Emotion Regulation Handout 8) is that there are myriad activities clients could engage in daily to
increase positive events and potentially positive feelings. Clients may not be engaging in enough of these to outweigh the negative or neutral events in their lives.

Emotion Regulation Skills

For each Emotion Regulation skill, check whether you used it during the week and describe
what you did. Write on back of page if you need more room.

REDUCED VULNERABILITY TO EMOTION MIND:
Treated physical illness?
ü
Balanced eating?
ü
Avoided mood-altering drugs?

Balanced sleep?
ü
Exercised?
ü
Practiced mastery?
I had a bad cold and took care of myself. Went to bed on time each night (and extra early when ill). Walked
with my friend two evenings this past week for exercise. Focused on eating healthy meals with reasonable
portions each day.

INCREASED POSITIVE EVENTS

Increased daily pleasant activities (circle):MTWTHFSSUN(Describe)
Listened to music during eve (Tues), took bubble bath (Fri), took pottery class (Sun).

LONG-TERM GOALS worked on:
Goal is to start dating again—(1) Took a picture for online profle, (2) worked on profle, (3) asked friends
for recommendations of good dating activities.

ATTENDED TO RELATIONSHIPS:
Called good friend from high school for frst time in months to catch up. Told sister I loved her and
wanted to work on improving our relationship.

AVOIDED AVOIDING (Describe)
Went to bank and got my account balance. Got on scale.

MINDFULNESS OF POSITIVE EXPERIENCES THAT OCCURRED

ü
Focused (and refocused) attention on positive experiences?
ü
Distracted from worries about positive experience?

MINDFULNESS OF THE CURRENT EMOTION

ü
Observed the emotion?
ü
Remembered:

ü
Experienced the emotion?
Not to act on emotion?

Times I’ve felt different?

OPPOSITE ACTION: How did I act opposite to the current emotion?

I’ve been feeling sad and ashamed about how much I weigh. Had urge to binge and sit at home. Instead, I
got out and went shopping for clothes I feel more attractive in.

FIGURE 5.2.
Example of a Steps for Reducing Painful Emotions Completed Homework Sheet.
Adapted from Linehan (1993b). Copyright 1993 by The Guilford Press. Adapted by permission.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to choose at least one positive event each day over the
following week in which to participate. Clients should keep track of such events,
perhaps using a homework sheet such as Appendix 5.6.

Building Long-Term Positive Events
Consider with clients how binge eating and other problem eating behaviors interfere with their ability to engage in and enjoy pleasant events in both the short and
long term and how having more pleasant events might help decrease their turning
to eating. Request that clients identify long-term goals they believe would contrib—
ute to their experiencing more satisfying, fulflling lives that would bring them
more happiness than they have currently. What small steps does each client need
to make to reach these goals?

Attending to Relationships

Talk over with clients the assumption that most individuals need good relationships to be happy and to have meaningful lives. What do clients need to do to
attend to the relationships in their lives? What could they do to make their relationships more rewarding? How does binge eating (and purging) interfere with
these relationships?

Avoid Avoiding

Point out how no one feels very positive if she or he is avoiding problem solving or
avoiding doing necessary things. Feeling masterful requires an active and positive
engagement with one’s life. As therapists explain, “Avoiding is similar to capitulating, convincing yourself that there is absolutely no other choice than to use food
in a given situation.” Passive avoidance or capitulating, as opposed to increasing
feelings of mastery, usually leads to negative feelings. The skill of Avoid Avoiding
involves actively blocking the option to misuse food (or engage in other problematic
behaviors) as an avoidance strategy.

Increasing Mindfulness of Positive Experiences
Clients with eating disorders, besides making too little time for positive events,
tend also to be highly skilled at destroying the positive emotions they do
have with
worry, guilt, self-punishment, and self-condemnation. Doing so has the effect of
wiping out these positive experiences, leaving clients with only feeting moments
of positive feelings. Therapists discuss, therefore, the reason that one of the skills
being taught is to be Mindful of Positive Experiences, letting them endure, instead
of spoiling your fun (so to speak) with secondary emotional reactions.

Clients, for example, may be laughing and enjoying themselves, only to destroy
that pleasure with a sense of shame that “I’m being too loud.” In other words, cli-

Emotion Regulation Skills

ents with problematic eating behaviors will typically undercut their sense of pride
and accomplishment with feelings of guilt (e.g., “I should not feel happy if others
are not happy” or “I should not experience pride about my own accomplishments if
someone else has been unsuccessful”).