Dialectical Behavior Therapy for Binge Eating and Bulimia (45 page)

Typical Prompting Events (e.g., dinner party, argument)
Typical vulnerabilities (e.g., overtiredness, alcohol)
Typical dysfunctional links (e.g., “What the heck,” “I deserve this,” “I can’t stand this without
eating,” “I know the skills are there but I don’t want to use them.”)
3.
Write about what you need to do next to continue building a satisfying and rewarding quality
of life for yourself.

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).

CHAPTER
8

Illustrative Case Examples
T
his chapter describes the application of DBT for BED and BN with two case
examples. The aim of these examples is to illustrate a typical course of therapy and
to offer guidance regarding issues likely to present the therapist with challenges.
The frst case example involves a client with BN whose treatment was delivered in
an individual format (twenty 50-to 60-minute sessions). The second case example
includes clients with BED who were treated via a group format (twenty 2-hour sessions).

Each treatment description includes the following:
••
••
••
••
••
••

Pretreatment session

Orientation to DBT (Sessions 1–2)
Core Mindfulness module (Sessions 3–5)
Emotion Regulation module (Sessions 6–12)
Distress Tolerance module (Sessions 13–18)
Review of skills and planning for the future (Sessions 19–20)
All clients whose treatment we describe consented to treatment and to having
their case material used in scholarly publications and for training purposes.

UTILIZING DBT IN AN INDIVIDUAL FORMAT FOR A CLIENT WITH BN
Clinical Presentation

Sarah was a 36-year-old Caucasian woman who met criteria for BN according to
the text revision of the fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders
(DSM-IV-TR; American Psychiatric Association, 2000) and who
was treated by one of us (D. L. S.).1
Sarah lived with her husband and their two
1A version of this case was frst published in Safer
et al.
(2001a).

Illustrative Case Examples

daughters, ages 7 and 5 years. She worked part time as a shop assistant, and her
husband worked full time as an engineer.

The Eating Disorder Examination (EDE; Fairburn & Cooper, 1993), a stan—
dardized interview for the assessment of eating-disorder diagnoses, was adminis—
tered at baseline. According to the EDE classifcation, Sarah reported 13 “objec—
tive” (i.e., eating an unusually large amount of food while experiencing a loss of
control) binge-eating episodes, 12 “subjective” (i.e., experiencing a loss of control
while eating an amount of food that would not generally be regarded as excessive)
binge-eating episodes, and 21 purging episodes over the preceding 28 days.

Sarah described being raised in a large family and recalled her mother as
emotionally distant, seeming always preoccupied with caring for Sarah’s mul—
tiple siblings and starting another new diet. She remembered feeling often that
she had not been “heard” in her family. Sarah frst began to diet in elemen—
tary school, portraying herself as slightly overweight and wanting to be thinner,
“more like the other girls.” Her binge eating and purging began when she was
23 years old. At that time she had just started working. Being away from home
and away from her support network from college, she found herself feeling very
lonely during the evenings. The course of her BN over the next 13 years waxed
and waned but had steadily become more severe. At the time she came to treatment she weighed 109 pounds and was 5 feet 2 inches tall (BMI = 20 kg/m2). She
reported her lowest weight as an adult as 109 pounds and her highest weight as
125 pounds.

Sarah reported that her binge eating and purging worsened coinciding with a
series of depressive symptoms occurring in the 4–6 months following the birth of
her frst child. During this period, 7 years prior to beginning the current treatment
program, she was also physically disabled due to a shoulder injury. She sought
counseling for 2 years. She found counseling helpful for her depressive symptoms,
though with little effect on her bulimic symptoms. She had never received psycho—
tropic medications. At the time Sarah sought treatment in our study, she did not
meet clinical criteria for major depression nor for any other Axis I or II disorders,
including current or past problems with alcohol or other substance abuse or depen—
dence.

Although clients with BED and BN entering our treatment studies often present with a variety of comorbid conditions (see Table I.1), Sarah’s case is presented
to maintain primary focus on illustrating the typical delivery of DBT as adapted
for BN. Her treatment consisted of 20 weekly 50-to 60-minute sessions of indi—
vidual psychotherapy. The initial 20 minutes of each session involved a review of
the homework/skills taught in the previous session, and approximately 30 minutes
involved didactic teaching of new skills (see Chapters 3–7, this volume).

Orientation to DBT: Pretreatment Interview and Sessions 1–2
Pretreatment Interview

The pretreatment session (see Chapter 3) is an opportunity to build a collaborative
relationship, to conduct some assessment of the presenting problem, to review the
affect regulation model of binge eating–purging, and to elicit the details of a recent

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

binge–purge episode. Additionally, the goals and targets of treatment are reviewed,
followed by discussion of the therapist’s and client’s treatment agreements.

After a brief introduction and welcome to therapy, Sarah was asked about why
she was seeking treatment at this point in time:

“My bulimia is the worst it has ever been in my life. I’m worried about the
effects of my behavior on my daughters’ chances of developing eating disorders.
This is not the role model I want to be. My bulimia is also making me ashamed
of myself as a person and is affecting my marriage. I don’t feel I can really talk
with him about what I’m doing.”

Sarah’s treatment history was reviewed, and it was established that this was
the frst time she had sought treatment specifcally for her eating disorder. As
noted, she had previously sought counseling for her depressed mood, and at that
time her eating behaviors were rarely if ever discussed. She was pleased that her
prior treatment helped to relieve her depressed mood but was disappointed that it
did not offer help for her eating-disorder symptoms.

Sarah was then introduced to the model of emotion dysregulation and was
shown the form in Appendix 3.1 (Chapter 3). This model, as was explained,
assumes an association between dysregulated emotions and dysfunctional eating—
disordered behaviors. Sarah was asked to describe a recent binge–purge episode to
determine the ft of the model for her problematic eating patterns. Sarah detailed
an episode that had occurred the night before, and the therapist asked, “What do
you think set it off?”2

sa r a h: I was really stressed, tired from working in the morning and then taking
care of the girls in the afternoon. I started thinking about binge eating when
I was supervising my older daughter’s homework. With school starting and my
husband traveling so much, I feel really pulled in many directions—all I could
start to think about was getting some time for myself and binge eating.
Th e r a p i sT: So what I’m hearing is—it was a diffcult day, work and the children
were completely draining, and to top it off, your husband was gone. I’m guess-ing that you were feeling frustrated at how much was expected of you by your
family and job, and maybe you were feeling lonely and unsupported by your
husband, not having him there to share these burdens. According to our model,
these emotions of frustration and loneliness are uncomfortable, and you don’t
think that you can handle them, so you turn to binge eating and purging,
which in our model is the overlearned maladaptive behavior. Does that sound
like I got it right?

sa r a h: Exactly.

Th e r a p i sT: How did it feel after you binged and purged?

sa r a h: I felt much calmer and centered. Well, at least initially.

Th e r a p i sT: Your experience does seem to ft with our model, in which binge eating
and purging work to help you numb out and avoid unpleasant feelings. This
2Modifed, rather than exact, transcriptions of sessions are reported due to space limitations.

Illustrative Case Examples

makes you feel better, as you said, at least initially. The reason you are here
is that there are longer term consequences, such as your shame about being a
poor role model for your daughters and feeling less close to your husband and
burdened by this secret that makes you feel that you’re not the person you
want to be. Does that seem right?

sa r a h: Yes—I’ve never heard it explained exactly like that. I always thought my
binge eating made no sense but I can see that, in an odd way, it does.
Th e r a p i sT: This treatment will teach you more effective ways to cope with your
emotions.

sa r a h: That sounds wonderful!

With Sarah’s assertion that the model explained her binge eating and purging
cycle well and her expressed motivation to learn more, the goals and treatment
targets of DBT were outlined (Chapter 3, Appendix 3.2). Sarah endorsed the stated
treatment goals and targets and agreed that stopping binge eating and purging
was her most important goal. Additionally, she understood that attending to any
behavior that interfered with her therapy would be important for the treatment to
run smoothly.

The therapist outlined the modules to be taught, as well as the general struc—
ture of each weekly 50-to 60-minute session. The Individual Client and Therapist
Treatment Agreements (Chapter 3, Appendices 3.4 and 3.5) were then reviewed.
As Sarah had no questions about these,3
she was asked to take them home to think
about them further before bringing them back. If she felt comfortable, she could
sign them. If not, the therapist would be happy to discuss them in more detail at
that time.

Introductory Sessions (Sessions 1–2)
SESSION
1

The goals of the frst session were: (1) to elicit a commitment to abstain from bingeing
and purging; (2) to present the biosocial model; (3) to orient the client to the diary
card and chain analysis; and (4) to review the client and treatment agreements.

The client’s commitment to abstinence from binge eating and purging is criti—
cal to obtain at the outset; hence, when Sarah returned, she was asked to further
describe the effects of binge eating and purging on her life and to outline her treatment goals. Sarah described feeling that her life was “in control in so many ways.”
She had daughters she loved, a good overall relationship with her husband, and a
satisfying job. The bulimic behavior seemed the only aspect that was out of control.
She also reported feeling that her eating disorder was a furtive secret she had been
hiding from others, including her husband, for a long time. Although her bulimia
had felt like her “best friend” when Sarah started engaging in it, over time it had
become a highly distressing and lonely burden.

3Sarah did not bring up concerns about potential weight gain, although many clients with eating disorders
do. Therapists can tell them that most bulimic clients do not experience much weight increase, if any (“usu—
ally not more than a couple of pounds”), after ceasing binge eating and purging.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA