Dialectical Behavior Therapy for Binge Eating and Bulimia (43 page)

At this point, therapists might check with clients regarding any further com—
ments. Next, it is vital that clients renew their commitment to abstinence. Therapists might say:

“Your commitment to abstinence from binge eating [and purging] is a critical
foundation on which you are building a happier life. That foundation must
be solid—the frm commitment that it is not
an option to use food to cope
with life’s stresses. With that commitment frmly established, you are free to
experiment with, explore, and apply the myriad adaptive skills you’ve learned
in this treatment. Remind yourself of the increased fexibility that comes from
living a life in which your behavior is not mood dependent, in which you have
the freedom to not
use food and to practice skillful means instead.”

Offer clients the choice to express their recommitment out loud or silently to
themselves. Suggest that clients reconnect with their commitment at least weekly,
perhaps daily, once treatment ends.

TREATMENT TERMINATION

It is normal and to be expected that both clients and therapists will have many
different thoughts and feelings about treatment coming to an end. It is important
to acknowledge this to clients and to allow time for discussion. Underscore that
the old habit of avoiding feelings is no longer an option. Termination provides an
opportunity to experience and express feelings, using the skills accordingly. Therapists might begin the discussion along the following lines: “It is normal to feel some
concern about the fact that therapy will be ending soon. Perhaps you are feeling
anxious or sad. Or at times feeling a sense of pleasure that it will be over because
you’ve gotten what you needed and feel ready to continue making progress on your
own. Or perhaps there are other emotions you are experiencing ... ?”

Review and Relapse Prevention

Clients may express a sense of loss, which therapists can validate with something such as: “Of course! This is a group in which you’ve been supported and have
been able to support others. Practice letting yourself maintain awareness of that
experience without judging it.”

Clients may experience anxiety as well. Highlight the importance of allowing
awareness of such feelings: “Your fears are not something to talk yourself out of. If
being in this group has helped you, it’s understandable that you may be frightened
about how you will maintain your commitment to your abstinence from binge eat—
ing [and purging] once treatment ends.”

The key point is for clients to use the opportunity near the end of treatment to
practice experiencing whatever emotions are coming up without turning to food.
Unlike at other times in their lives, when they may have turned to food or other
means to numb themselves to emotions with which they lacked skillful means of
coping, clients no longer have to miss the chance to emotionally experience events
in their lives—including the upcoming termination. Help clients to be as specifc
as possible about their feelings, pointing out that vague descriptions, such as “I’m
feeling upset,” may actually cover up more in-depth understanding. At this point
in treatment clients can recognize times at which they are speaking to themselves
in ways to avoid being close to their deeper emotional experiences.

DISCUSSION
P
OINT: “What emotions are you aware of experiencing about the
upcoming end of treatment?”

REVIEW OF SKILLS

Explain that the purpose of the review is to strengthen skill acquisition, and
underscore that if the skills are to be of beneft, practice is an ongoing, lifelong
commitment. Emphasize that the skills are always an available option for clients
to use if they turn their Wise Minds to them. It is particularly relevant to fortify
practice of the skills, as more feelings regarding termination will likely surface
after treatment ends.

Mindfulness Module

Begin the review of Mindfulness by emphasizing how the Mindfulness skills truly
serve as the foundation for the rest of the skills clients were taught. This is why
they are considered the core skills. The “What” and the “How” skills are the keys,
the tools to accessing Wise Mind, and are cultivated on a daily basis. Initiate a
brief discussion about the three states of mind: Reasonable Mind, Emotion Mind,
and Wise Mind. For example, are clients able to identify what state of mind they
are in? How do they use this information to direct their coping efforts? Have clients
engaged in a regular practice of accessing their Wise Minds? If so, “What” do they
do to fnd this state of mind? How does fnding Wise Mind help clients realize their
goals?

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Briefy review the “What” skills, asking clients to describe each “What” skill
in their own words. If needed, offer a few general points such as: “Observe
involves
stepping back from your experience, noticing without getting caught up in or cling—
ing to that experience—allowing your experience to come and go. Describe
involves
putting words on experiences. It involves labeling a thought as a thought or putting a name to feelings.” Remind clients of the tendency we all have to believe that
because a thought enters one’s mind, it must
be true. However, obviously, this is not
the case. By describing to oneself and labeling a thought as a thought, for instance,
one is better able to have an objective stance toward one’s experience. With Participate, clients are practicing being fully in the moment.

Review the “How” skills in a similar fashion, asking clients to describe each as
if they were teaching it to a friend. If needed, therapists can add to the discussion
with reminders such as:

“Nonjudgmentally
means ungluing opinions from facts, acknowledging but not
judging, and looking at what has occurred—what is. One-Mindfully
involves
practicing patience in the moment. It is patiently bringing one’s full attention to
the present moment and keeping the mind from going off in multiple directions
or becoming distracted. One-Mindfully is accepting the present, one moment
at a time, while letting go of competing distractions. Effectively
is focusing on
what works. It is doing what needs to be done in each situation.”

Remind clients that Effectively is not about what is fair or what is right or wrong.
When being Effective, one’s focus is on playing by the rules, keeping one’s eye on
one’s objectives. Acknowledge that it may not be fair that clients have urges to
binge (and purge) and others do not. Being Effective means playing with the cards
one was dealt and not cutting off one’s nose to spite one’s face. Other potential ques—
tions for discussion might include:

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“‘How’ do you get to your Wise Mind?”

“‘How’ do you focus your attention instead of remaining mindless and in the
grip of Emotion Mind?”

“‘How’ do you Observe, Describe, and Participate?”

The Mindfulness “What” and “How” skills underlie Mindful Eating, Urge
Surfng, and Alternate Rebellion. Mindful Eating
is eating with full awareness
and attention and without self-consciousness or judgment. Urge Surfng
entails
the nonattached observing of urges to binge (and purge), riding the urge out without trying to block, stop, or fght it. Alternate Rebellion
includes being effective by
fnding alternate means to rebel that do not involve binge eating. One uses rebel—
liousness in ways that do not backfre and result in greater diffculties. Encourage
clients to describe their use of these skills, including times they have had trouble
with them and times they have been able to use them to steer clear of binge eating
(and purging).

Review and Relapse Prevention

Enumerate each of the goals of the Emotion Regulation module, asking clients to
refect on one key idea that was important or meaningful to them for each of the
following: (1) identify your emotions; (2) explore the function of your emotions; (3)
reduce your vulnerability to Emotion Mind; (4) increase your positive emotions;
(5) decrease your suffering by using Mindfulness to let go of distressing emotions;
and (6) use Acting Opposite to emotion behaviors to change your emotional experience.

Include a review and discussion of the following ideas and skills: Observing
and Describing one’s emotions, experiencing one’s emotions as a wave, and remem—
bering that one is not one’s emotion. The idea is to honor all one’s experiences, not
judging oneself or one’s emotions, to reduce emotional suffering. Underscore that
Acting Opposite to the Current Emotion
can be a powerful way to change or reduce
the intensity of an emotion that is interfering with the quality of clients’ lives.
For example, if clients feel down or depressed, they may avoid social engagement,
potentially prolonging their negative moods. Acting Opposite to the Current Emotion would involve approaching the situation and opening the possibility of a dif—
ferent, positive experience. Acknowledge that this skill does not offer a “quick fx”;
its benefts derive from repeated practice.

A sampling of questions to ask as part of the overall discussion include:
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“Which Emotion Regulation skills are your ‘strongest’—the ones you feel
most confdent about being able to access?”

“Which Emotion Regulation skills need more of your focus and practice? For
example, is it easy to identify the action urge associated with an emotion but
hard to clarify the interpretations you’re using?”

“What are the functions of emotions?”

“How do binge eating [and purging] and other problematic eating behaviors
interfere with the function of emotions? For example, how would binge eating when angry interfere with communication, organizing action, and self—
validating?”

“What have been your observations regarding the idea that fghting your
experience tends to increase suffering?”

“What has been your experience with Acting Opposite to the current Emotion?”

“Think about the strongest emotion you experienced this past week. What
were your body sensations, your action urges? Could you have changed your
interpretation? Could you have changed your physical sensations?”
“What has been your experience with reducing your vulnerability to Emotion Mind? What would be your current goals?”

“What kinds of positive events have you been adding to your life?”
“Have you been working to avoid avoiding?”

“What has been your progress on your long-term goals (e.g., attending to
relationships)?”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Distress Tolerance Module

Begin the review of this module by reminding clients of the idea underlying these
skills—that pain is an inevitable part of life. The Distress Tolerance skills are
aimed at helping clients endure distressing or uncomfortable situations without
making the moment worse, such as through binge eating (and purging).

Distinguish between the two types of Distress Tolerance skills: Acceptance
skills (e.g., Radical Acceptance, Observing Your Breath, Half-Smiling, and Aware—
ness Exercises) and Crisis Survival skills (e.g., Distracting, Self-Soothing, Improv—
ing the Moment, and Thinking of Pros and Cons). Remind clients that turning to
the Crisis Survival skills is not intended to solve the problem nor necessarily make
it go away, but to help clients survive the crisis without making things worse.

Recall for clients that a crisis does not have to be huge in order for them to use
their Crisis Survival skills. They can turn to them any time they have an urge to
binge (and purge), eat mindlessly, or fnd themselves facing cravings.