Dialectical Behavior Therapy for Binge Eating and Bulimia (37 page)

Adapted from Linehan (1993b). Copyright 1993 by The Guilford Press. Adapted with permission in Dialectical
Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice Y. Chen (2009).
Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright
page for details).

151

APPENDIX 5.5

Observing and Describing Emotions Homework Sheet
EMOTION NAME(S)
Intensity
(0–100)
PROMPTING EVENT
for emotion (who, what, when, where):
INTERPRETATIONS
(beliefs, assumptions, appraisals) of situation:
BODY CHANGES and SENSING:
What am I feeling in my body?

BODY LANGUAGE: What is my facial expression? Posture? Gestures?

ACTION URGES: What do I feel like doing? What do I want to say?

What I SAID or DID
in the situation (Be specifc):
What AFTEREFFECTS
does the emotion have on me (state of mind, other emotions, thoughts,
etc.)?

FUNCTION OF EMOTION:
Adapted from Linehan (1993b). Copyright 1993 by The Guilford Press. Adapted with permission in Dialectical
Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice Y. Chen (2009).
Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright
page for details).

APPENDIX 5.6

Steps for Reducing Painful Emotions Homework Sheet
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?

Balanced eating?

Avoided mood-altering drugs?

Balanced sleep?

Exercised?

Practiced mastery?

INCREASED POSITIVE EVENTS

Increased daily pleasant activities (circle): M T W TH F S SUN(Describe)
LONG-TERM GOALS worked on:
ATTENDED TO RELATIONSHIPS:
AVOIDED AVOIDING (Describe):
MINDFULNESS OF POSITIVE EXPERIENCES THAT OCCURRED
Focused (and refocused) attention on positive experiences?
Distracted from worries about positive experience?

MINDFULNESS OF THE CURRENT EMOTION

Observed the emotion?
Remembered:
Experienced the emotion?
Not to act on emotion?

Times I’ve felt different?

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

Adapted from Linehan (1993b). Copyright 1993 by The Guilford Press. Adapted with permission in Dialectical
Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice Y. Chen (2009).
Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright
page for details).

APPENDIX 5.7

Adult Pleasant Events Schedule (Abbreviated)

1.
Soaking in a bathtub

2.
Going on vacation

3.
Relaxing

4.
Going to a movie in the beginning of the week

5.
Laughing

6.
Lying in the sun

7.
Flying kites

8.
Going to a party

9.
Arranging fowers

10.
Reading fction

11.
Gardening

12.
Going hiking

Adapted from Linehan (1993b). Copyright 1993 by The Guilford Press. Adapted with permission in Dialectical
Behavior Therapy for Binge Eating and Bulimia
by Debra L. Safer, Christy F. Telch, and Eunice Y. Chen (2009).
Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright
page for details).

CHAPTER
6

Distress Tolerance Skills

T
he aim of teaching Distress Tolerance skills is to equip clients with a variety
of strategies to use in the present moment
when they are experiencing pain, diffculty, or distress that cannot be changed right away. Essentially, Distress Tolerance skills are designed to teach clients how to bear pain skillfully. The idea is
that everyone inevitably has to face pain and diffculty that is not within his or
her control (e.g., natural disasters, illness, death of loved ones). At these times, it
is critical to avoid making matters worse and to refrain from reacting in unskillful ways (e.g., binge eating, substance use) that can increase the pain and suffering. Although what is happening may be beyond one’s control, one can
choose
to respond skillfully until things change. That is, eventually things will change
(circumstances, emotions, etc., don’t last forever), and using Distress Tolerance
skills in the interim will put one in a better position when and if something can
be
done to improve things. At the heart of the Distress Tolerance skills is learning to
develop patience, tolerance, and equanimity (nonreaction) in the face of diffculty
that cannot be changed right away.

There are two different sets of Distress Tolerance skills: skills for Accepting
Reality and Crisis Survival skills. Skills for Accepting Reality
will enable the client
to accept life as it is in the moment and cope with painful situations that cannot
currently be changed. Specifc skills include Observing Your Breath, Awareness
Exercises, Half-Smiling, and Radical Acceptance (see Appendix 6.1). Crisis Survival skills
are designed to facilitate the client’s ability to bear short-term painful
situations. Their aim is to help clients “carry on” and remain functional without
resorting to behaviors that make things worse. Specifc skills include Distracting,
Self-Soothing, Improving the Moment, and Thinking of Pros and Cons (see Appendix 6.1).

Underlying the Acceptance of Reality skills is the notion that accepting, fac—
ing, and tolerating reality puts one in a stronger position to cope skillfully in
the world, whereas trying to deny, fght, or avoid reality undermines coping and
increases suffering. That is, acceptance encourages awareness such that under—
standing and compassion are more possible. Fighting, denying, or avoiding painful
feelings decreases awareness and engages one in a struggle that therefore is not

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
fully understood, increasing the likelihood of further suffering. Living skillfully
involves accepting that pain and distress cannot be entirely avoided.

It is important to clarify that acceptance of reality does not imply approval
of reality. Acceptance is not about approval or disapproval but involves simply
acknowledging reality as it is rather than denying it. Clients can simultaneously
accept reality and not like or not approve of it. As therapists acknowledge, things
one likes are often easier to accept. The struggle is usually in coping with things
one dislikes.

Crisis Survival skills are designed to provide clients with specifc strategies
to use when they are overwhelmed, feel unable or unwilling to accept the situation
they are in, and/or cannot seem to locate their Wise Mind. Crisis Survival skills
allow one to obtain much-needed momentary relief and a temporary break from
overwhelming emotions so that, when returning to handling the crisis situation,
one can do so in a different state of mind.

In summary, Distress Tolerance skills are aimed at helping clients learn to
bear pain skillfully. By using Distress Tolerance skills to tolerate painful emotions
when called for in that moment, clients can, paradoxically, reduce
the intensity and
duration of pain and suffering and enhance
a feeling of mastery by using skillful
means and wise responding. It is important that therapists highlight how Distress
Tolerance skills are linked to the client’s goals of stopping binge eating (and/or
purging).

DISCUSSION
P
OINT: “What are your reactions to this material and its aims of teaching
you to get through a diffcult situation without making things worse, as well as how to
survive a crisis when the situation cannot be changed right away? Can you think of times when
trying to avoid pain led to more problems than it solved? How has binge eating or purging been
used to avoid pain? How effective has it been, especially when viewed over the long run?”

DISCUSSION
P
OINT: “Can you think of times when you needed to distract yourself or
put your pain on the ‘back burner’ because it was not an appropriate time to work on
changing or fguring out or resolving your painful emotions?”

Therapists emphasize here that the distracting from or setting aside of one’s
pain is skillful. The purpose is to come back to it when the timing might be bet—
ter. Also, the stepping back permits a calmer perspective. This is not denying or
avoiding. Therapists might use the following story, or one from personal or clinical
experience, to illustrate the potential consequences of attempting to deny reality
and avoid pain.

ILLUSTRATIVE
Ex
AMPLE

OF
A
TTEMPTING
TO
D
ENY
R
EALITY
AND
A
VOID
P
AIN

“A client in her 20s was denying her feelings about a relationship in an attempt to
avoid the pain of ending it and experiencing loss. She didn’t want to truly admit
to herself how angry, hurt, and invalidated she felt. By avoiding her feelings and

Distress Tolerance Skills

refusing to accept that the relationship was not working for her, she prolonged
her suffering and stayed in the relationship for a year longer than was in her best
interests. Looking back on this in later years, she realized that denying the reality
meant enduring an additional year of this painful relationship and produced more
pain than would have been the case if she had left when she knew it was time. If
she had accepted the reality of her emotions and the pain of the situation a year
prior, these emotions would have functioned to help her change the situation and
end the relationship.”

DISCUSSION
P
OINT: “Can you think of times when you accepted painful feelings?

What was that experience of acceptance like for you? What can you recall about the
consequences of accepting rather than fghting your experience?”

OBSERVING YOUR BREATH

A useful skill that facilitates accepting reality is learning to be in the moment, one
breath at a time. Breathing is something clients always have available to them. As
therapists point out, no additional materials are needed. The skill of Observing
Your Breath is designed to help center yourself or focus yourself on a single object
in order to settle or calm the mind. This is a particularly useful skill to employ
when you are agitated, overwhelmed, distracted, and/or preoccupied. Observing
Your Breath can help to access the Wise Mind.

There are many variations and examples of this skill. For example, clients
might practice observing their breath when listening to music, when walking,
when carrying on a conversation, and so forth (see Linehan, 1993b, Distress Tolerance Handout 2, pp. 170–171).

Therapists may wish to use the following script, modifying it as needed, to lead
clients in the experiential exercise of counting breaths as an example of Observing
Your Breath.

ExPERIENTIAL
Ex
ERCISE:
OBSERVING
Y
OUR
B
REATH

“Get into a comfortable position with your feet on the foor, head and spine straight,
and breathe in and out from your diaphragm, taking slow, deep, rhythmic breaths.
Choose a spot on which to focus your eyes, or gently close them. Bring your atten—
tion to your breath coming in and going out. Try to settle your body, keeping the
breath in mind as your anchor. As you inhale, be aware that you are inhaling.
When you exhale, be aware that you are exhaling. If you are feeling anxious or
experiencing some discomfort as you breathe, just note this and gently turn your
mind to breathing in and out. Make your breathing as comfortable as possible. If
breathing from your diaphragm is not comfortable for you, fnd a spot to focus the
breath that is comfortable for you. Now, as you inhale, begin counting by saying:
‘I am inhaling ... one.’ Then, as you slowly exhale, say: ‘I am exhaling ... one.’
Keep counting—‘I am inhaling ... two’ ... ‘I am exhaling ... two’—until you reach