Dialectical Behavior Therapy for Binge Eating and Bulimia (39 page)

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
exercises include awareness while washing dishes, walking slowly in a circle, tak—
ing a slow-motion bath, applying lotion, and so forth.

The Awareness Exercises involve utilization of the core Mindfulness skills, or
the ability to nonjudgmentally participate with awareness. Many of these exercises,
including Observing Your Breath, Half-Smiling, and Awareness, are adapted from
the book The Miracle of Mindfulness: A Manual of Meditation
by the Zen master
Thich Nhat Hanh (1999). Clients who would like further reading on mindfulness
and the acceptance of reality exercises are referred to this book.

The following short experiential exercise can be used to help clients practice
awareness, modifying the script as needed.

ExPERIENTIAL
Ex
ERCISE:

AWARENESS
W
HILE
A
PPLYING
S
CENTED
L
OTION

“Lavender-scented lotion is being passed around. Practice being aware and fully in
the moment as you smooth the lotion on your hands and skin. The idea is to participate with awareness, focusing your attention on just the moment you are in.”

DISCUSSION
P
OINT: “What was that like? Were you able to be fully present for your
experience, or did you fnd your mind wandering off? Do you think you are usually
present for these types of everyday experiences, or are you on automatic pilot? How do you
think these awareness exercises could help facilitate emotional acceptance and disrupt the
path to binge eating, purging, or mindless eating?”

RADICAL ACCEPTANCE

Radical Acceptance involves letting go of fghting reality through accepting from
deep within oneself, at the core of one’s being. The word “radical” is Latin for “root.”
In other words, Radical Acceptance involves accepting reality at its root or core.
It is not a superfcial type of acceptance. Rather, it is characterized by the serenity prayer, which, as clients may know, says, “Grant me the serenity to accept the
things I cannot change, the courage to change the things I can, and the wisdom to
know the difference.” Ultimately, Radical Acceptance involves accepting the way
things are; there are circumstances that cause pain and that one cannot change;
one must accept the resulting pain. Additionally, Radical Acceptance is accepting
that one must change the things that one can and accept the complicated, tough,
and painful feelings about the situation, as well as any that may arise as a conse—
quence of making changes.

Radical Acceptance can be a powerful tool for clients as they struggle to
change the things they can (i.e., binge eating, purging, and other maladaptive eating behaviors). Practicing Radical Acceptance can be very helpful for clients who
experience bodily symptoms after stopping compensatory behaviors (e.g., edema,
or swelling, after cessation of laxative abuse). Practicing Radical Acceptance would
involve accepting both the physical and psychological discomforts of a Wise Mind
decision to change.

Distress Tolerance Skills

The following exercise can be used to introduce clients to the concept of Radical Acceptance, modifying as needed.

ExPERIENTIAL
Ex
ERCISE:
RADICAL
A
CCEPTANCE

“Sit up straight in your chair, feet on the foor, with your hands resting comfort—
ably. Pick a place to focus your eyes (or gently close them) and take a moment to
focus your mind on your breath. Now, think back to a time in your life when you
were given bad news, something that at frst you didn’t accept. [Pause] Perhaps
it was a loss of some sort, or a death. Remember what you felt at the time. What
were your initial emotions? Was your tendency to avoid your feelings or deny the
reality of what was happening? [Pause] Now, think about when you were able to
acknowledge what had happened and accept the reality of the situation. Describe
the difference between those two experiences—your nonacceptance of the reality of
the situation and your acceptance of the situation. Take a moment now to practice
Radical Acceptance of the pain you experienced as a consequence of the situation
you brought to mind. Take fve deep, fowing breaths, slowly opening your eyes if
you had them closed, as we end the exercise.”

DISCUSSION
P
OINT: “What did you notice about the two experiences—when you did
not accept the reality of the situation and when you did accept it?”

Emphasize that acceptance is not the same thing as resignation or passivity.
Indeed, not only is acceptance not antithetical or contrary to change, but acceptance is required for change, for being able to act. Clients must frst accept the
reality of a situation before they can act to change it. Not accepting a situation
leaves one stuck.

Following is a clinical example used in our groups to make the preceding point
regarding the necessity of accepting something in order to bring about change.

ILLUSTRATIVE
Ex
AMPLE:
ACCEPTANCE
I
S
N
OT
P
ASSIVITY

“Imagine the terrible situation of a child being molested by a babysitter. For many
people, if this happened to their child or to a child they knew, the tendency would be
to deny the situation, at least at frst, because the reality feels too painful to face.
But one has to at least face up to the reality of the situation in order to act—for
example, informing the authorities or removing the child to a safe situation.

“Or think about the example of binge eating [and purging]. If you deny or
continually avoid facing the truth that you are eating in a disordered way or try to
ignore how hurtful and disruptive this behavior is to your life, does this increase or
decrease the likelihood that you will remain stuck in the behavior?

“In other words, acceptance is a choice. You can live facing reality or you can
ignore reality. Radical Acceptance is making the choice to accept the moment,
whatever it is, and thus accept the pain. Paradoxically, Radical Acceptance may

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
transform your experience. Fighting painful feelings and refusing to accept that
pain is an inevitable part of life can interfere with reducing pain and instead may
lead to prolonging pain and suffering.”

It is useful to acknowledge the impulse clients may experience to accept something while holding onto a secret hope that doing so will mean that they will not
have to experience pain. Therapists will want to make clear that acceptance is not
an internal bargaining chip; clients cannot say “OK, I’ll accept this intense disappointment, but the deal is that the disappointment will automatically go away.”
When clients are trying to use acceptance as a technique to create change, they
are not really accepting. Clients are not practicing accepting the reality from deep
within.

Therapists should also point out that acceptance does not mean having to give
up hope that a situation will improve or that one’s pain will decrease. Clients can
hope for these changes but should not necessarily expect use of Radical Acceptance
to make them feel better.

Suffering Is the Nonacceptance of Pain
Therapists defne suffering as the struggle to keep pain out of awareness. In other
words, suffering is pain plus
the nonacceptance of pain. The struggle to escape or
deny pain ensures that clients remains engaged in the effort not to accept things as
they are. This, as a result, creates suffering. Being stuck fghting reality and not
accepting pain generates and maintains suffering.

The good news about the skill of Radical Acceptance, as therapists should
describe, is that it can transform the struggle of suffering into the experience of
this current moment’s pain. It cannot be overemphasized that acceptance does not
mean that pain goes away. But acceptance means that one does not suffer as much.
Pain may be unavoidable, but when the client accepts it, she or he is dealing only
with the pain rather than with the pain plus
the nonacceptance of that pain.

DISCUSSION
P
OINT: “Can you think of examples from your life in which you experienced
Radical Acceptance?”

Therapists may fnd the following experiential exercise useful in helping clients practice Radical Acceptance, modifying as needed.

ExPERIENTIAL
Ex
ERCISE:

ACCEPTING
THE
P
AIN
OF
A
C
URRENT
S
ITUATION

“Sit comfortably in your chairs, choosing a place for your eyes to focus. Bring to
mind something you are not accepting now. Perhaps there is some situation, some
aspect of your reality that you are resisting or fghting. As you bring that thing to
mind, practice accepting it, practicing acknowledging it. You are practicing accepting the reality of the situation. This acceptance may mean acknowledging that this

Distress Tolerance Skills

is a situation you can do nothing about, at least for the moment. Or the acceptance
may mean acknowledging that there is something that you can do, that there are
changes you must make. Practice acceptance right now of whatever you might be
fghting, denying, or resisting.

“Remember as you practice the acceptance that you are acknowledging reality.
If a situation has caused you to become hurt, Radical Acceptance means accepting
this pain as a consequence of that situation, as a reality that has occurred. This
means accepting it as just what is. Think about how we accept gravity. We do not
feel we have to like it or approve of it. But we are able to accept that objects fall as
a consequence of gravitational forces. Radically accepting gravity allows us to let
go of struggling against such realities. We do not have to be ‘OK’ with gravity to
radically accept it, nor must we remain passive.”

Turning the Mind

The frst step toward Radical Acceptance is being aware that you have the choice
to accept. When you notice yourself turning away from acceptance, it is possible
to turn your mind back to the path of acceptance. Turning the Mind is the oppo—
site of capitulating. Capitulating is refusing to see any path but one. It is saying,
for example, “I have no other options. The only thing I can do here is use food.”
Capitulating closes off the path of acceptance, of the reality of the situation that
just occurred, and involves rigidly staying on whatever maladaptive path one is on,
refusing to even consider, let alone choose, another path.

Turning the Mind is the frst step toward opening oneself up to another option.
Clearly, simply acknowledging the existence of another path or bringing to clients’
awareness that they have a choice does not mean that they will necessarily take
that path. But clients are more likely to do so if they are aware that this option is
there.

DISCUSSION
P
OINT: “Can you give an example of a time when you recognized that
there was another option than remaining caught in a struggle that was not effective?”

Willingness and Willfulness

After one becomes aware of the choice to take the path of acceptance, Willingness
is needed. Willingness is the state of doing what is necessary in each situation. It
involves focusing on effectiveness, listening carefully to one’s Wise Mind, acting
from one’s inner self. Willingness is allowing the awareness of a larger perspec—
tive, the awareness of a broader meaning to the things that are happening that
one dislikes.

Willfulness is refusing to do what is needed in the situation or, metaphorically,
sitting on one’s hands when action is needed. Willfulness can mean giving up, or it
can mean trying to fx every situation, refusing to tolerate the moment.