Dialectical Behavior Therapy for Binge Eating and Bulimia (44 page)

Emphasize that Acceptance is not about passivity. Indeed, Acceptance may
involve facing and acknowledging that change must take place.

In reviewing the Distress Tolerance module, therapists may wish to ask:
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“How would you describe in your own words why you need to learn Distress
Tolerance skills? What are they good for? What is their rationale?”
“How has learning the Distress Tolerance skills improved your ability to
regulate strong emotional states?”

“How have the Distress Tolerance skills replaced impulsive Emotion Mind
behaviors such as bingeing [and purging]?”

“What are the major categories of Crisis Survival skills? Which have you
tended to use? Which do you plan to try more in the future?”

“What has been your experience with thinking in terms of the Pros and
Cons of tolerating distress?”

“How have you used the Acceptance exercises, such as Observing Your
Breath?”

“What has been your experience with Half-Smiling?”

COPING AHEAD1

After the review, therapists present Coping Ahead, the last new skill to be taught.
This skill is particularly useful at this juncture, with treatment ending. As opposed
to writing a chain analysis of a problem eating behavior, in which the idea is to
examine the past to try to better understand what could have been done differ—
ently, Coping Ahead aims to move that analysis into the future.

As therapists clarify, this skill is one to turn to when clients are anxious about
how they may respond in a particular situation. For example, if clients know they
are vulnerable during social events with plentiful food, clients might practice Coping Ahead to help them manage more effectively during the actual event. This
1This skill was termed “Mental Simulation” in the original DBT for BED and BN manual and research.

Review and Relapse Prevention

might entail imagining themselves going to an upcoming party, anticipating in
detail what it would be like to experience urges to binge (and purge), and imagining in detail their use of skills to adaptively cope with those urges.

The key to Coping Ahead is to be very specifc. Practicing Coping Ahead for the
preceding situation, clients might imagine asking themselves what their Wise Mind
would say. In addition, they might practice Radical Acceptance—rehearsing mov—
ing through the steps of Turning the Mind. They might also imagine identifying
their emotions (e.g., anxiety, sadness) and examining their function. This might be
followed by mentally simulating and practicing the skill of Burning Your Bridges
to binge eating (and purging). Coping Ahead could also involve clients observing
and developing new perspectives on the situation and on their responses.

Coping Ahead involves rehearsing in detail what clients would actually say to
themselves and what they would actually do. By practicing Coping Ahead, clients
may receive powerful reassurance that that they will be able to effectively use
their skills to cope with diffcult situations and that their emotional states do shift
and pass. Emphasize that when clients mentally simulate turning to skills and
surviving diffcult situations, they are more likely to know what to do when actually facing these circumstances.

ExPERIENTIAL
Ex
ERCISE:
OBSERVING
Y
OUR
B
REATH

“Get into a comfortable position with your feet on the foor, head and spine straight,
and breathe in and out from your diaphragm. Choose a spot on which to focus your
eyes. Allow your mind to imagine a future situation in which you are likely to experience urges to binge [and purge], eat mindlessly, or engage in other problematic
eating behaviors. This may be an actual upcoming situation or one that, based on
your past experience, you can anticipate being diffcult—such as a holiday celebra—
tion at which you typically overeat. Practice Coping Ahead by seeing yourself in
detail experiencing the situation. Picture what you are doing, saying, and feel—
ing. Mentally simulate turning to the skills to cope effectively with the situation.
For example, imagine practicing Observing Your Breath as you fnd out what your
available food choices are. Imagine seeking guidance from your Wise Mind. Really
see yourself in detail practicing turning to the skills. As you do, observe whether
any obstacles come up. If so, mentally simulate coping with those obstacles. For
example, if you imagine that you might begin to overeat and experience the urge
to capitulate and binge [and purge], mentally simulate Turning Your Mind toward
the path of Willingness. Cope Ahead by remembering the skill of dialectical abstinence, radically accepting what you have done as you recommit to abstinence from
this moment forward. Imagine identifying your emotions and thinking about their
function. See yourself gaining a new perspective, handling the situation effectively,
and being nonjudgmental with yourself. When you are ready, take several deep
breaths and end the exercise.”

DISCUSSION
POINT: “What was your experience of Coping Ahead? Can you think of
other future situations in which you might turn to this skill?”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
If time permits, the following general questions may be helpful as part of a
fnal review:

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“What skills have you found most useful?”

“Are there some that are particularly useful for certain instances, and others for different circumstances?”

“Which skills did you fnd it diffcult to practice or that need more practice?”

“What interferes with your practice of those skills?”

“Specifcally, how have you used skills to replace binge eating [and purging],
mindless eating, and other problematic eating behaviors?”

Planning for the Future

Distribute the Planning for the Future Homework Sheet (Appendix 7.1). Its goal is
to help clients think specifcally about strategies for maintaining treatment gains
and for continuing to make further progress after treatment ends. In our research
protocols, this handout is distributed in the second-to-last session to allow clients
time to refect, make plans, and discuss their plans during the fnal session.

Therapists might say:

“Here is a Planning for the Future sheet. We ask you to seriously consider the
issues represented on it. Our next session is our last. During the second half of
the session, each of you will have the opportunity to share parts of your Planning for the Future homework sheet. The handout asks you to describe your
specifc plans for continuing to practice the skills taught in the program. For
example, you may decide to continue to keep the diary card as a record of your
skills practice and set a goal to practice at least one skill each day. You might
identify the fve skills that you practiced the least and the fve skills you found
the most helpful and develop a plan to practice these each day.

“The second activity on this sheet involves identifying how you will deal
with specifc emotions in the future that previously set off problem eating for
you. For example, have you often reacted to anger or anxiety by binge eating
[and purging]? The purpose of having a plan is to be able to implement it to
prevent any problem eating behaviors. We know that with the treatment program ending, the most important things for you will be to continue with your
skillful behaviors and healthy eating and to maintain your abstinence from
problem eating behaviors. As part of this exercise, you may also want to focus
on remembering your typical dysfunctional links, the ones you’ve had to work
through in the past. Was it the thought ‘I deserve food’ or ‘It doesn’t matter’ or
‘Food will help me feel better’? Which skills were most useful for dealing with
these links? The third activity on the sheet is to write about what you need to
do next to continue building a rewarding, satisfying way of life.”

Review and Relapse Prevention

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to complete the Planning for the Future Homework
Sheet (Appendix 7.1) and be prepared to discuss it at the next session.

FINAL SESSION

Therapists may wish to structure the fnal session similarly to that followed in
our research studies. The frst half of this last session, like preceding sessions,
is devoted to reviewing each client’s report of his or her skills practice and chain
analyses of any problem eating behaviors.

After the break, clients are given the opportunity to provide feedback about
their experience in treatment. This is followed by a review of each client’s plan for
the future. Good-byes are then said.

Feedback

Therapists may wish to use and/or adapt the following questions, introducing them
by explaining: “Because we are continually developing this treatment program and
hope to further improve, we would like to spend a few minutes fnding out about
your opinions and experiences.”

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“How did this treatment program go for you?”

“In what ways did the treatment help, and how did it fail to help you?”
“Did you fnd input from other group members helpful?”

“What has been important for you about the group?”

“Would you have preferred to receive treatment on a one-to-one basis through
individual treatment? [Or for those receiving individual treatment] Would
you have preferred to receive treatment in a group therapy format?”
“In your opinion, were there too little, too many, or just the right number of
skills taught?”

“Did you fnd the in-session practice exercises, such as the Mindful Eating
exercise and Half-Smiling, to be helpful to you?”

“How did the homework review portion work for you?”

“What were your favorite skills?”

“How did this treatment help in other areas of your life?”

“Do you have any ideas on issues that we haven’t yet discussed that would
help improve the treatment program?”

Planning for the Future

Clients share their responses to the Planning for the Future homework sheet with
the group.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

Good-byes

Therapists may wish to say good-bye to the group by expressing admiration for
clients’ hard work and appreciation for their sharing and participation. This may
be stated generally or with specifc reference to each client. Communicate belief
and confdence in the clients’ abilities to continue to build a high quality of life for
themselves, one that is free of problem eating behaviors.

In our experience, group members often take the initiative to give parting
gifts to one another (e.g., a piece of heavy parchment paper with inspiring quotes,
a CD with songs that group members would likely fnd moving and meaningful).
(Note: Chapter 9, Future Directions, includes a discussion of handling the issue of
relapse.)

APPENDIx
7.1

Planning for the Future Homework Sheet

1.
Write about specifc plans you can put into place to help you continue to practice the skills that
have helped you during this program.

2.
Think of circumstances and emotions that previously tended to set off binge eating.

For example, identify your typical prompting events, typical vulnerabilities, and typical
dysfunctional links. Write about at least one of each and outline your plans for the skills you
would use in each circumstance to deal with the typical emotions that are generated. In other
words, how will you prevent a binge or other problem eating behavior? Please use the back of
this page as needed.