Dialectical Behavior Therapy for Binge Eating and Bulimia (40 page)

Willingness is making an agreement with oneself that one will accept reality
and act skillfully as opposed to willfully refusing to deal with reality on its own
terms.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
The following illustrative example may be useful for clients in making the dis—
tinction between willingness and willfulness.

ILLUSTRATIVE
ExAMPLE:
WILLINGNESS
AND
W
ILLFULNESS

“Imagine that for months you had planned a very special outdoor garden party.
As the event approaches, the forecast calls for rain. Willfulness would be denying
the forecast, saying, ‘No—it is not
going to rain. I’ve been planning and planning.
I don’t have room for an indoor party, and this party is going to be outside and it
won’t rain.’ Then, on the day of the party, it rains, and you’re furious. Willfulness
is refusing to go with reality on its own terms. Willingness, on the other hand, is
deciding that the forecast may be accurate and making arrangements, even if you
would rather not, to be able to move the party indoors if needed or renting tents so
that your guests can still be comfortable if it rains.

“If life is like a card game, then you have a choice to play the hand that you
have been dealt as skillfully as you can, being mindful of and accepting your cards.
This is choosing willingness. Or you can throw your cards down and say, ‘I’m not
going to play. It’s not fair.’ That’s willfulness.”

DISCUSSION
P
OINT: “Do you see binge eating and/or purging as being willful? Do you
use food as a way of sitting on your hands when action is needed? Is it a way of giving
up, trying to fx every situation, refusing to tolerate the moment? What are your thoughts?”

TROUBLESHOOTING
P
OTENTIAL
D
IFFICULTIES
IN
T
EACHING
R
ADICAL
A
CCEPTANCE

••
Example 1: “Is Radical Acceptance the same thing as forgiveness?”

••
Potential therapist reply: “Radical Acceptance should not be confused with
forgiveness. Forgiveness is a choice, not a necessary outcome of Radical Acceptance.
Practicing Radical Acceptance helps you honor your emotions (e.g., hurt, anger,
resentment) and the fact that they are present. Once these emotions are acknowl—
edged, you may choose to forgive by acting opposite to your emotions and to the
action urges associated with them. Forgiveness comes easier to some than others.
You may want to forgive if enduring these emotions interferes with your quality of
life. When you’ve radically accepted your hurt and anger, you may be able to forgive
if you develop a sense of compassion for the person who caused your pain. It’s your
choice whether you want to reach forgiveness.”

••
Example 2: “Why do I fnd it so hard to accept things even when it’s in my
best interest?”

••
Potential therapist reply: “I know you’re not sure, but has anything come to
mind about what you think makes it diffcult to take the frst step of turning your
mind toward acceptance? Perhaps these ideas might be helpful in triggering some
thoughts. For some of us, what makes it hard is the fear that, if we are willing to
accept things as they are, that means that we, our situation, or the problems we’re

Distress Tolerance Skills

struggling over will never change. If that rings true for you, it might be helpful
to remind yourself that acceptance does not mean you are powerless or passive. It
might also be helpful to think about how ‘acceptance’ is about accepting the way
things are in this one moment, not all moments to come or moments that have
passed. It also may help to refect about what is effective for you in a situation.
Sometimes we must accept that we must work to do what is needed in order to be
effective—and that this includes dealing with reality the way it is.”

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to practice Radical Acceptance (including Turning the
Mind and Willingness) by spending some time each day purposefully focusing on
this skill. Specifcally, clients may fnd it helpful to keep track of how distressed
they feel (on a scale of 1–100) prior to practicing Radical Acceptance and how distressed they feel afterward.

BURNING YOUR BRIDGES

Burning Your Bridges is another Radical Acceptance skill. It involves accepting, on
a very deep level, that one is really never going to binge (and purge) again. Clients
“burn” the binge eating (and purging) bridge so that this behavior is not an alter—
native. What is radical about this skill is that it involves saying, “Regardless of my
experience, turning to food just won’t be an option. There are other ways I am going
to deal with whatever my experience is.”

Therapists can point out that practicing Burning Your Bridges is similar to
what people who stop smoking by going “cold turkey” do. These individuals make a
pact that this will be their last cigarette. No matter what cravings or experiences
arise, it is not an option for them to smoke. Burning Your Bridges involves Radical Acceptance of one’s experiences. It may also mean that clients act to cut off all
options to binge eat (and purge). In other words, clients may practice this skill by
disposing of binge foods, by not engaging in certain situations that have repeatedly
made them vulnerable to binge eating and purging, or by not engaging in those
apparently irrelevant behaviors that almost always lead them, sooner or later, to
misuse food.

The following experiential exercise can be used to further illustrate this skill,
modifying the script as needed.

ExPERIENTIAL
Ex
ERCISE:
BURNING
Y
OUR
B
RIDGES

“Make yourself comfortable in your chair, with an erect posture, your head up
straight, and your feet on the foor. Take several deep breaths from your dia—
phragm—choosing a place to focus your eyes. Now, imagine that you are on the
coastline looking out at an island from the shore. This island is ‘Binge Eating [and

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Purging] Island.’ Imagine what this island of binge eating [and purging] looks like.
Next, picture the water separating you from the island flled with sharks, with the
only way to reach the island being a bridge.

“Now, imagine placing a stick of dynamite on each slat of the bridge. It may
be helpful to think about what the slats symbolize for you, such as the individual
behaviors that make it possible for you to continue to reach Binge Eating [and
Purging] Island. These might include your personal apparently irrelevant behaviors—for instance, hosting parties and not getting rid of leftovers or shopping when
you’re ravenous. Take time to identify those situations or apparently irrelevant
behaviors that your Wise Mind knows end up, sooner or later, leading you to Binge
Eating [and Purging] Island.

“Once you’re safely back on shore, imagine detonating the dynamite. Visualize
each slat of the bridge blowing up, one by one, until the whole bridge has exploded.
You’ve now burned your bridge to Binge Eating [and Purging] Island. Binge eating [and purging] is not an option ever again. Take a moment to imagine being in
a situation in which you feel an urge to binge or purge and looking back out to the
island and saying, ‘Oh, I’ve burned that bridge, it’s just not an option.’”

DISCUSSION
P
OINT: “What came to mind? How did it feel to imagine feeling an urge
and knowing the bridge was blown up?”

After teaching Burning Your Bridges, it is often a natural time to have clients
recommit to stopping binge eating (and purging). The following sample script for
leading clients through the recommitment exercise can be modifed as needed.

ExPERIENTIAL
Ex
ERCISE:

RECOMMITTING
TO
S
TOPPING
B
INGE
E
ATING
(
AND
P
URGING)

“As was mentioned, people who make commitments to do something are more likely
to be successful. So what we’d like you to do is to recommit, out loud, to the same
commitment you made during the frst session—to stop binge eating [and/or purging]. But now, as compared with then, you know so many more skills, and many of
you already have stopped binge eating [and/or purging]. So this is taking it a bit
further and fully committing yourself to never taking the bridge to binge eating
[and/or purging] again. That path never worked for you. Avoiding your emotions
and using food as a way of coping brought you to the point at which you came into
this program. You had recognized that binge eating [and purging] was preventing
you from building the quality of life you wanted and that you had to stop in order
to build an authentic relationship with yourself and others and to feel that you
were living up to your potential. Take a moment and get in touch with your Wise
Mind and, if and when you’re ready, recommit to stopping binge eating [and/or
purging].”

DISCUSSION
P
OINT:
“What was that like for you?”

Distress Tolerance Skills

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to practice bringing up the image of Burning Your
Bridges to binge eating (and purging) at least once a day. Using the homework
sheet (Appendix 6.2), clients can write about their practice of this skill, including
their thoughts and feelings about their use of it.

CRISIS SURVIVAL SKILLS
Introduction to Crisis Survival Skills
This next group of Distress Tolerance skills, the Crisis Survival skills, is introduced by explaining that these strategies are intended to help clients survive a
crisis without making matters worse. Crisis Survival skills can be extremely use—
ful for those painful events and emotions about which nothing can be done, at least
not at the current moment.

According to the dictionary, a crisis is defned as a “turning point” in the
course, a crucial time, stage, or event. In other words, a crisis is a time of danger or
trouble whose outcome decides whether possible bad consequences will follow. The
synonym for a crisis is an emergency.

Emphasize that a crisis can be a turning point in that the way clients handle it
affects the outcome. Interestingly, as some clients may already know, the Chinese
symbol for crisis is apparently the merging of two symbols—the symbol for danger
and the symbol for opportunity. Put another way, a crisis entails both the danger
that one can react to—thus potentially making the situation worse (e.g., by turning to binge eating)—as well as the opportunity to respond more adaptively. Not
making matters worse may in and of itself be very affrming.

Remind clients of the point made earlier in the module: that the Crisis Survival skills should not be reserved for only the “big” crises in one’s life. Crises exist
in varying degrees of severity, the minicrises and the bigger ones. Furthermore,
what one client defnes as a crisis may not ft another’s defnition. These skills can
be used for the daily minicrises that make a client’s life more stressful.

When everything else the client is doing is not working for her or him, and it
feels as though all her or his skills have gone out the window, the Crisis Survival
strategies are the skills to try to practice. In other words, crises (both big and
small) occur when one feels unable to accept one’s situation, does not feel willing,
and cannot seem to locate Wise Mind.

Therapists clarify that Crisis Survival skills are not intended to solve the crisis but to provide momentary relief so that when clients return to handling the
crisis situation they can do so in a different state of mind. Caution clients that
Crisis Survival skills are not meant to be overly used, as they can lose their effec—
tiveness over time. In addition, they are not intended to be the only skills clients
use, because these skills were not designed to and thus do not solve longer term
problems. In other words, these are very valuable skills, but it is important that
they be a part
of the clients’ repertoires of skills.