Dialectical Behavior Therapy for Binge Eating and Bulimia (42 page)

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

As with the other Distress Tolerance skills, it may be helpful for clients to track how
effective each different Crisis Survival skill is so that eventually they will have an
idea of which ones tend to be most helpful. Clients can keep notes of which catego—
ries of skills were used (e.g., Distracting, Self-Soothing, Improving the Moment),
which specifc skill was tried (e.g., taking a bubble bath as a way of Self Soothing with touch), and the distress experienced before (from 0–100) and after (from
0–100) a particular skill was used.

Therapists instruct clients to practice trying at least three different Crisis
Survival skills each day over the following week or until the next session in order
to become familiar with all of them.

Thinking of Pros and Cons

This Crisis Survival skill gives clients a chance to think, in a very deliberate way,
of the pros and cons of tolerating their distress and the pros and cons of not tolerating it. It can be very helpful for surviving a crisis.

In thinking of the pros of tolerating the distress without engaging in a poten—
tially self-destructive behavior, clients might frst bring their attention to the posi—
tive consequences of tolerating their distress. For example, clients might imagine
how good they will feel if they don’t act impulsively in this moment. They might
focus on the light at the end of the tunnel or their long-term goals and how good it
feels to make progress toward them instead of feeling as if they are taking steps
backward.

In thinking of the negative consequences of tolerating the distress, clients
might refect on the very real advantages of times when they act impulsively to try
to avoid the pain of the current moment. Using food can really work to temporarily
manage painful feelings and allow one to numb out or avoid them.

Clients should then direct their attention to thinking about the pros of not
tolerating the distress. This may or may not be similar to the disadvantages of
tolerating their distress without turning to food. The question to ask oneself is:
What are the advantages of allowing myself to act impulsively and binge eat (and
purge)?

Finally, clients should think about the disadvantages of not tolerating their
distress. What has acting impulsively and binge eating (and purging) cost the clients in the past? What would it cost currently—or in the near future—in terms of
their self-confdence, mood, relationships, physical well-being—their overall qual—
ity of life?

Therapists might use the following exercise to give clients the experience of
practicing the skill of Thinking of Pros and Cons, modifying as needed.

Distress Tolerance Skills

ExPERIENTIAL
Ex
ERCISE:
PROS
AND
C
ONS

“Take a piece of paper and pen. Take a moment to think about and write down the
pros of tolerating, during a crisis, the distress you’d be experiencing. What are the
benefts of acknowledging the reality of the pain and truly trying to survive the
experience without making it worse? Then, what are the disadvantages of tolerating those emotions and not turning to solutions that will offer short-term relief?
After considering those, write down the advantages of not tolerating the painful
emotions and allowing yourself to impulsively turn to food or engage in another
problematic behavior. Finally, identify and write down the disadvantages of not
tolerating the pain, bringing to mind your experience over time, as well as its impli—
cations for the present and your future.”

DISCUSSION
P
OINT: “What are you aware of by having flled this out? How do you want
to respond next time you are facing a crisis?”

TROUBLESHOOTING
D
IFFICULTIES
IN
T
EACHING
C
RISIS
S
URVIVAL
S
KILLS

••
Example 1: “I don’t understand when I should be using the Crisis Survival
skills versus when I should be using Emotion Regulation or Mindfulness skills.”

••
Potential therapist reply: “The decision about when to use each skill is a Wise
Mind type of decision. I’m not suggesting that you should always distract yourself,
for example, or use one of the other Crisis Survival skills when dealing with your
emotions. There are defnitely times when you need to be acting based on your emotions. But at the times when you feel so overwhelmed that you cannot access your
Wise Mind and you experience a strong urge to binge [and purge]—that is, you are
in Emotion Mind—the Crisis Survival skills give you a way to just survive that
moment without turning to behaviors that will not only not help you to respond
effectively but will actually make matters worse. Binge eating [and purging] or
pulling the covers over your head are ineffective responses because they compound
the problem, leaving you faced with both the crisis and the negative consequences
of binge eating [and purging].”

••
Example 2: “I’m confused about the difference between distracting with
opposite emotions and Acting Opposite [from the Emotion Regulation module].”

••
Potential therapist reply:
“That’s an important question! The Distress Tolerance skill of distracting with an opposite emotion really focuses on getting a quick
result to help you manage yourself through a crisis. It allows you to take a break.
When you are using Acting Opposite as an Emotion Regulation skill, you are making a long-term change to address an emotion that isn’t working for you. Temporar—
ily, acting opposite of emotions you wish to change can cause increased distress—
such as when you approach something, such as getting on an airplane, that you
fear. But over time, the emotion will diminish if you continue to act opposite. The
anxiety will decrease, for example, if a person continues to approach airplanes
instead of avoiding them.”

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

Therapists instruct clients to review, during the week, the Thinking of Pros and
Cons that they wrote during the session. As clients face crises, be they big or small,
and notice urges to turn to food, they should work through on paper additional pros
and cons (e.g., pros of tolerating the distress, cons of tolerating the distress, pros of
not tolerating the distress, cons of not tolerating the distress). Rating their distress
(on a scale of 0–100) before and after practicing the skill will help clients evaluate
its effectiveness for them.

APPENDIx
6.1

List of Distress Tolerance Skills to Be Taught

••

Observing Your Breath

••

Half-Smiling

••

Accepting Reality Awareness

••

Radical Acceptance (Turning the Mind, Willingness
versus Willfulness)

••

Burning Your Bridges

••

Crisis Survival skills (Distracting, Improving the Moment,
Self-Soothing, Thinking of Pros and Cons)

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

APPENDIX 6.2

Burning Your Bridges

Burning Your Bridges is accepting at a very deep level that you are never going to binge and/
or purge again. It is burning the “binge eating (and purging) bridge,” the bridge that you’ve
traveled across to allow yourself to engage in these behaviors. Burning that bridge means that
binge eating (and purging) will no longer be an option, that you are making an active choice that
this method will no longer be your way to “solve” your problems or cope with diffcult situations
when your emotions seem overwhelming. It is a radical concept because you are accepting that,
regardless
of your experience, the behavior of turning to binge eating (and purging) will not exist
as an option. You are making a decision from deep within that there are other ways that you can
regulate your emotions and that you must instead turn to them.

Burning Your Bridges can be paralleled with the experience of smokers who stop “cold turkey.” It
is that type of radically accepting one’s experience. It is accepting and acknowledging that you
are going to have painful and distressing experiences and emotions and that you will deal with
them without the option of binge eating (and purging). It may also mean that you act to cut off
all options that tend to lead you to binge eat and/or purge (apparently irrelevant behaviors, etc.).
Depending on your particular circumstances, for example, it may mean disposing of the foods on
which you binge.

Instructions: Describe what Burning Your Bridges means to you. Do you have a picture of a
burning bridge? Are there steps you would want to take now to cut off the options? Use the
remainder of this sheet, including the back, if you need extra space.

Adapted from Telch (1997a). Copyright 1997 by Christy F. Telch. 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
7

Final Sessions
Review and Relapse Prevention
T
he fnal sessions of treatment are devoted to addressing several important
issues. These include:
••

••
••

••

Renewing clients’ commitment to abstinence and using the skills instead of
binge eating (and purging).

Processing feelings associated with the treatment coming to an end.
Reviewing the skills in order to emphasize their application and to under—
score that practice is a lifelong endeavor.

Discussing strategies for preventing posttreatment relapse.

There is much to cover, and therapists will need to be sensitive both to the
needs of their particular group or individual client and to the importance of allow—
ing adequate time to discuss the material.

RENEWING COMMITMENT TO ABSTINENCE AND USING THE SKILLS

As treatment nears to a close, it is vitally important that clients renew their commitment to abstinence from problematic eating behaviors and their commitment
to using skillful means. The aim is to strengthen clients’ resolve regarding the
cessation of their binge eating (and purging) and the adoption of the skills in place
of problem eating behaviors. With this in mind, therapists ask clients to recall
the commitment they made at the start of treatment. How has this commitment
infuenced their behavior, thoughts, and experience? Allow a few clients to com—
ment. Next, therapists might summarize their own perspectives along the follow—
ing lines:

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
“Each of you had the courage to undertake this treatment and make a commitment to yourself to work toward cultivating a happier, more satisfying life,
one in which you feel much better about yourself, more vital, more confdent.
You promised yourself that you would honor yourself by directly experiencing your life instead of using food to blunt or escape diffculties. Understand—
ably, at times you may feel a sense of deprivation or loss when consciously
deciding to relinquish the familiar habit of binge eating [and purging] to cope.
Although these behaviors have some short-term ‘upsides,’ our discussions at
the beginning of treatment led to the heartfelt insight and convincing conclu—
sion that continuing to binge eat [and purge] was not compatible with living
up to your fullest potential. You’ve learned that not
acting on the urge to binge
[and purge] is a great freedom and have felt empowered by your choice to turn
to skills. You have become less driven by and reactive to your emotions and are
instead developing a mindful awareness of what is taking place inside of you
and responding with skillful means.”