Dialectical Behavior Therapy for Binge Eating and Bulimia (38 page)

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
ten. When at ten, return to counting with one. Practice keeping your mind fully
engaged in the breathing. Any time your mind wanders, just bring it back to the
exercise and begin again at one.”

DISCUSSION
P
OINT: “What was your experience with the exercise? Did the practice help
in attending to and accepting the moment?”

Therapists are advised to underscore the importance of practice. Observing
Your Breath can be practiced at various points throughout the day. Five or ten
minutes of practice three or four times a day will pay off over time and strengthen
one’s ability to use this skill in times of stress. Observing Your Breath can be done
in a variety of contexts, including those daily struggles, annoying situations, and
minicrises that one seems to continually confront. Additionally, clients can use
the skill of Observing Your Breath at times when they feel the urge to do something unskillful or destructive (e.g., reaching for something to eat) in response to
unpleasant feelings they are having about a particular situation (e.g., not wanting
to accept that heavy traffc will make them 15 minutes late). Not every challenge
can be avoided. If a person tries to respond to and change every stressful thing
in his or her life, he or she is likely to end up frustrated and plain worn out. This
exhaustion can, in turn, make one more vulnerable to urges to turn to food. Practicing the skill of Observing Your Breath on a daily basis can fortify a client’s ability to nonreactively accept the reality of her or his situation.

DISCUSSION
P
OINT: “Are you experiencing a distressing situation in your life right now? If
so, could you imagine applying the Observe Your Breath skill to that situation?”

Therapists may want to conduct the following experiential exercise to illus—
trate applying the skill of Observing Your Breath.

ExPERIENTIAL
Ex
ERCISE:

COUNTING
Y
OUR
B
REATHS
W
HEN
Ex
PERIENCING
D
ISTRESS

“Sit comfortably in your chair with an upright but not rigid posture and begin to
focus on your breathing. Choose a focus point for your eyes or gently close them.
Bring your full attention to breathing in and out as comfortably as you can. Let
your mind settle as best you can, keeping your attention on your breathing. Now
bring a distressing situation to mind. See yourself in the situation, picturing what
you are doing, saying, and feeling. Then see yourself in the situation using the skill
of Observing Your Breath. See yourself maintaining a focus on breathing despite
the reality of the distressing situation. See yourself being patient with the breath,
nonreactive, acknowledging what is happening but not fghting what is. Remember
that you don’t have to do
anything in this moment to alter what is, and that accepting the situation is not the same as approving it. Just stay with observing your
inhalations and exhalations and do not get pulled away or distracted by thoughts or
feelings regardless of how compelling they are. Stay with the breath as your center

Distress Tolerance Skills

even as you are aware of the distress ‘at the edges.’ Observing any accompanying
thoughts or feelings is a part of Observing Your Breath. Practice till you get to a
count of ten. Then end the exercise.”

DISCUSSION
P
OINT: “What were your experiences when practicing Observing Your
Breath? Did your distress lessen, intensify, or stay the same? Can you imagine
employing this skill? When might it be useful to you to do so? What result would you hope to
achieve?”

DISCUSSION
P
OINT: “What are your reactions to the idea that there does not have to be
a resolution to your distressing situation and that, indeed, there is not always a pain-free
solution available to many of life’s biggest challenges? What do you think the effect would be
of fnding out you can survive and tolerate the distress you are experiencing without making it
worse?”

SUGGESTED
HOMEWORK
P
RACTICE

Therapists should encourage clients to remember as they practice these skills that
truly learning to accept the moment and tolerate whatever diffcult feelings are
present should help lessen the intensity of clients’ urges to block or change their
feelings through binge eating and/or purging.

1.
Therapists instruct clients to practice an Observing Your Breath exercise
each day. This might involve counting their breaths, observing their breath when
listening to music, observing their breath when walking, or observing their breath
when carrying on a conversation.

2.
Therapists encourage clients to discover which is their favorite.

HALF-SMILING

The skill of Half-Smiling is a very powerful one. For many clients it becomes a
favorite. The skill’s aim is to facilitate clients’ inner acceptance by having them
adopt an outer facial expression of acceptance—the half-smile. When one’s facial
muscles are tight or one’s jaw is set, it is very diffcult to accept something. The
outer tightness is incompatible with an accepting inner attitude. With Half-Smiling, the muscles of the face are relaxed. By adopting a half-smile—a serene, accepting smile—clients increase their chances of experiencing internal acceptance.

Experimental evidence shows that one’s facial expression communicates with
one’s brain. We are accustomed to thinking about our brains communicating with
our faces; we internally experience an emotion (e.g., sadness, happiness) that sends
a signal to our faces (e.g., to frown, to smile). Yet there is evidence that the communication also works in the other direction. For example, in one study (e.g., Laird,
1974), participants were asked to place their facial muscles in various positions.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
The positions were added slowly and were so out of sequence that the participants
did not know what position their faces were in. Participants whose outer expressions were angry were more likely to experience anger inwardly, those whose outer
expressions were sad were more likely to experience sadness inwardly, and so forth.
That is, the research found that one’s outer facial expressions communicate with
and give feedback to one’s brain.

Half-Smiling is not intended to be used to avoid or deny one’s experience. One
employs Half-Smiling with the knowledge that it is skillful to do so under the cir—
cumstances. While fully aware of the myriad experiences one may be having, one
chooses to promote the experience of acceptance by adopting a half-smile. This skill
helps clients to access their Wise Mind, which accepts reality skillfully with aware—
ness but without judgment. Clients need not completely understand the source or
basis of their distress in choosing to practice the Half-Smiling skill. Wise respond—
ing involves tolerating their experience.

Clients are taught how to practice the skill of Half-Smiling. The following
experiential exercise can be used, modifying the script as needed.

ExPERIENTIAL
Ex
ERCISE:
HALF-SMILING

“Begin by putting your face in a neutral position. If it helps, close your eyes, though
this is not required. From the neutral face, make a very angry face, one you’d make
if you were really infuriated. If you are having diffculty, try to imagine a situation
in which you were absolutely livid or ‘ft to be tied.’ As your face is in this position,
pay attention to your inner experience. Now change your expression to the neutral face again, taking several deep breaths from your diaphragm. Now, create the
facial expression you make when you are afraid or highly anxious—a face of fear.
If needed, think of a time when you were really and truly afraid. Once again, pay
attention to your inner experience as you make the facial expression of fear.

“Now, place your facial muscles in a neutral position again, taking several
deep diaphragmatic breaths. Now, adopt a sad expression, perhaps one that is grief
stricken. Pay attention to the inner experience accompanying this facial expression. Then, come back to the neutral face, taking a few moments.

“Now, turn the corners of your mouth up very slightly into a half-smile. It is
important to remember that when you half-smile, your face is completely relaxed.
Imagine any tension fading away, as if a cool iron were smoothing the muscles of
your face, neck, and shoulders, helping them to relax. Your forehead, eyes, cheeks,
and jaw muscles are just ‘hanging’ on your face. Ever so slightly, turn up the corners of your lips toward your ears. It’s just a slight upturn of the lips, not really a
smile, but still perceptibly different from the neutral face. This half-smile is not
a tense expression, nor is it a grin or a smirk. Perhaps it might help to think of
the Mona Lisa’s smile. Stay with that position, and pay attention to your internal
experience.”

DISCUSSION
P
OINT: “What did you notice about your inner experiences when you
adopted the different outer facial expressions? What was your experience of the half-smile? Did you notice a greater feeling of being open to acceptance?”

Distress Tolerance Skills

If helpful, emphasize the point made earlier that in choosing to put on a
half-smile, clients are not masking, denying, or hiding their emotions. Half-Smiling involves acknowledgment of whatever one’s experience is, followed by
the decision to call up a different experience. The client is choosing to facilitate
inner acceptance by placing her or his facial muscles into an accepting, relaxed
pattern.

Therapists remind clients of the Model for Describing Emotions (Chapter 5,
Appendix 5.2). According to that model, a stimulus causes the brain to react, trig—
gering certain neurochemical and facial muscle changes. Half-Smiling changes
the emotional experience by changing the client’s facial expression. This feedback
changes the client’s brain chemistry. Compared with some of the other acceptance
skills that clients will be taught, which involve thinking
about one’s experience differently, adopting a half-smile is a physical
behavior that clients can employ as a
catalyst for change.

SUGGESTED
HOMEWORK
P
RACTICE

1.
Therapists instruct clients to list situations that would be useful for practicing Half-Smiling—situations in which they cannot change the reality of their
circumstances and fnd it diffcult to achieve acceptance (e.g., waiting in line, being
stuck in traffc, having one’s bus, train, or plane delayed).

2.
Therapists encourage clients to practice Half-Smiling at least once a day to
gain familiarity with this new skill. Suggest that clients practice this skill when
they experience an urge to binge and/or purge.

GUIDELINES FOR ACCEPTING REALITY: AWARENESS ExERCISES

The purpose of the Awareness Exercises is to practice keeping one’s attention
focused in the current moment, fully aware and present. Awareness Exercises
help cultivate the ability to be aware of each moment, and practicing these skills
strengthens awareness and acceptance in the moment so as to develop a more
accepting state of mind. Emphasize that learning and strengthening the ability to
accept reality as it is, without making it worse with behaviors such as binge eating
and/or purging, is extremely valuable. If well practiced, these skills can be highly
cherished tools for helping one accept and tolerate the reality of very tough times.
Acceptance is not intended to include acceptance of the state of things as they are
for eternity but acceptance of how things are in the moment. Thus the emphasis
with acceptance is on awareness of the current moment.

It is best to practice these or any new skills and to build one’s “Awareness”
muscle by selecting relatively simple tasks and situations, as opposed to compli—
cated emotional situations, as one’s focus. The Awareness Exercises involve practicing being mindful of tasks such as making tea or coffee or brushing one’s teeth
rather than solving complex equations or preparing a tax return. It is best to practice awareness of simple daily activities at the outset. Other ideas for experiential