Dialectical Behavior Therapy for Binge Eating and Bulimia (46 page)

The following exchange illustrates how the therapist encouraged Sarah’s com—
mitment to her goal of abstinence.

Th e r a p i sT: From what you’ve told me, it really sounds like the bingeing and purging is having a signifcant negative impact on many important areas of your
life. Does that feel true?

sa r a h: Oh yes. Very true. It used to be such a comfort and would make me feel less
stressed out. But now it seems to have a life of its own. I feel guilty and lonely,
and it doesn’t really help me with the stress, at least not for very long at all.
Th e r a p i sT: I understand. It really does sound like it seriously interferes with the
quality of life you want. However, despite the negatives, there are clearly some
reasons why you continue doing it. Can we make a list of what some of the

benefts of continuing might be?

sa r a h: Well, there aren’t too many. But I guess ... well ... when I get all stressed
out and overwhelmed by trying to juggle the kids’ homework, my job, trying to

be both parents when my husband’s job takes him out of town—that’s when the

bulimia can make me feel kind of more relaxed just after I’ve done it.
Th e r a p i sT: I see. It helps, at least in the short run, to distract you from the stress
and release some of the tension. Any other upsides?

sa r a h: I get lonely when my husband’s out of town, so it can be kind of a comfort.
Th e r a p i sT: That’s important—again. The bingeing and purging seems to serve to
distract you from diffcult feelings. And it’s temporarily successful.

sa r a h: I kind of get to have my cake and eat it, too, and not put on weight. That’s
also good.

Th e r a p i sT: Hmm. I know you’re here because you want to stop, but I have to say,
there is a lot that works about the bulimia. Perhaps you should reconsider.

Maybe there’s a way to work out continuing to binge eat and purge and also

develop a life really worth living. Do you think that’s possible, rather than trying to eliminate the binge eating and purging?

sa r a h: (Is silent for a moment, then protests.) I don’t think you’re getting it right.

See, even if it makes me less stressed out just after I vomit, I still have to go
back out there and somehow juggle everything. And because vomiting takes

so much out of me, I’m so exhausted that I don’t do as well as I could. Like

I’m such a mess afterward I can’t think straight. And even if it makes me less

lonely when Dave is out of town, I’m married to Dave—and not to sticking my

head down the toilet. And it’s awful because I can’t even bring myself to tell

him about it—so having bulimia makes me even lonelier. He’d be so upset if

he found out—not only because of how it is affecting my health but because

he’d feel like I’d been cheating on him. We’ve shared everything in our rela—

tionship but this. And eating what I want and not putting on weight. Well, I

hardly actually enjoy the food when I’m binge eating. And vomiting is gross.

It makes your breath smell. Even if it’s helping to control my weight I’m not

sure I look good—the truth is I just look and feel worn out. No. Having buli-

Illustrative Case Examples

mia and having the life I want to live—I just can’t do both—I’ve tried and you
can’t do it.

Th e r a p i sT: I can hear the defeat in your voice. That you’ve tried to have both the
bulimia and a life that’s meaningful for you, and it has not worked out. They’re
not compatible.

sa r a h: They’re not.

Th e r a p i sT: Well, you’ve convinced me. OK—then that’s it. From what you’ve said,
there’s no other way. You’ve got to stop the binge eating and vomiting and
you’ve got to stop them now.

sa r a h: Now?

Th e r a p i sT: Yes—the last binge and vomit you had—we’re going to christen them
your last.

sa r a h: Really? But I can’t just stop it like that.

Th e r a p i sT: Why not?! I don’t see that you have much choice. You can’t juggle all
the things you do, have a completely honest relationship with your husband,
deal with your job and the kids, and be the kind of mother you want to be—
unless you stop the binge eating and vomiting. I’m convinced from what you’ve
said that if you keep binge eating and vomiting, things will only get worse.

Your only hope is to stop the binge eating and vomiting.

sa r a h: Okay. Well, I do want to stop it, that is why I came. ...

Th e r a p i sT: You don’t sound so sure. Really consider what it means to give up the
pros that the bingeing and purging temporarily offer. There may even be others that we haven’t discussed. However, remember that the aim of this treat-ment is to teach you skills to manage all the stress and diffcult emotions you
describe. In the meantime, while you learn and practice the new skills, you’ll
need to draw on whatever skillful resources you already have but that may be
rusty at this point.

sa r a h: Well—I could try to stop.

Th e r a p i sT: That’s a great place to start. But we know from research and our
experience that it takes more than trying to stop binge eating and purging.

You need to make a genuine commitment—from the deepest part of yourself. A
commitment from the part of you that wants to live up to your potential, be the
kind of role model for your daughters that you respect, and have a healthier
and more open relationship with your husband. Do you feel you can make that
commitment?

sa r a h: Yes. I can commit to stopping bingeing and purging. But I’m so afraid
I won’t be able to keep that commitment. What if I binge and purge after I
leave?

Th e r a p i sT: We’re not asking you to predict the future. We’re just asking that you
make a commitment right here, right now, in this moment, to stop. After all,
life is just a series of moments, and we have the opportunity to recommit from
moment to moment.

sa r a h: Well, OK. I can commit right now.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Th e r a p i sT: That’s a brave thing to do.

Following this, Sarah and the therapist reviewed the Individual Client and
Therapist Treatment Agreements (Chapter 3, Appendices 3.4 and 3.5). Sarah was
reminded of the structure of future sessions, with the frst 20 minutes devoted
to reviewing homework and the remaining 30 minutes devoted to learning new
skills.

The therapist then introduced the chain analysis (Chapter 3) and explained
that using this chain is a skillful behavior. Sarah was given instructions for completing the chain. This began by reviewing the path to mindful eating hierarchy
(Chapter 3, Appendix 3.2), clarifying that the highest targets on the path (e.g.,
binge eating and purging) were to be written about before those lower on the list
(e.g., apparently irrelevant behaviors). The role of the prompting event, or environ—
mental trigger that precipitates the chain of problematic behaviors, was discussed,
as well as vulnerability factors (e.g., lack of sleep, physical illness). The links
of
the behavioral chain, which include a client’s actions, body sensations, cognitions,
events, and feelings, were reviewed, and more skillful behaviors to replace the problem behaviors were identifed. Sarah was directed to complete at least one chain
analysis (Chapter 3, Appendix 3.8) prior to the next session with the help of the
sample chain and guidelines (Chapter 3, Appendices 3.6 and 3.7).

Finally, Sarah was given a diary card and instructions for flling it out (Chapter
3, Appendices 3.9 and 3.10) and asked to record the frequency of targeted behaviors
(e.g., binge eating and purging), to rate the presence and intensity of various emo—
tional states, and to note which skills were practiced each day. She was told that at
each session this would be reviewed, so it was important that she bring it weekly.

SESSION
2

This session’s goals included reviewing the homework and teaching the new skills
of dialectical abstinence and diaphragmatic breathing (see Chapter 3). The session
began with a review of Sarah’s diary card. Sarah had flled the card out for 4 of the
previous 7 days. She said that she did not fll her card out for 3 days because she
had binged and purged on those days and felt too ashamed to write about these
behaviors. She also did not fll out a chain analysis.

The therapist explained that the incomplete homework was an example of ther—
apy-interfering behavior and suggested that she and Sarah fll out a chain analysis
together to better understand Sarah’s not completing all of her homework.

T
h e r a p i sT
: As we discussed last time, anything that stops you from participating
in treatment is our number one priority. (Brings out a blank chain analysis
form.) So, how was it that you didn’t fll in Saturday, Sunday, and Monday of
your diary card?

sa r a h: I just couldn’t. (Looks down and becomes quiet
.)

Th e r a p i sT: Tell me about what happened.

sa r a h: The truth is that when I made the commitment not to binge I thought it
would not happen ever again.

Illustrative Case Examples

Th e r a p i sT: It sounds like shame got in the way of you and the diary card.
sa r a h: Well, yes—I guess.

Th e r a p i sT: You’ll be learning a new skill today that I think will really help you to
cope with this shame without having to avoid your homework. Now, let’s do a
chain of your last binge.

The therapist and Sarah conducted a chain analysis of her previous binge and
purge.

After reviewing homework, the therapist turned to teaching new skills. The
therapist reassured Sarah that many clients fnd it diffcult to cope with contin—
ued binge eating and purging despite their commitment to stop and explained
that the skill of dialectical abstinence is specifcally taught at this juncture to
help clients understand, perhaps in a way they never have, the possibility of rein—
forcing their commitment to a goal even when they fail to reach that goal in the
moment.

It was suggested that the skills, dialectical abstinence and diaphragmatic
breathing, in addition to the diary card and chain analysis, were tools that Sarah
could use to help her when she experienced urges to binge and purge during the
following week.

Core Mindfulness Module: Sessions 3–5

In these sessions, Sarah was taught core mindfulness skills to increase her ability
to be aware of and experience her feelings without reacting to them by engaging
in emotion-driven eating behaviors (e.g., binge eating and purging). Specifc skills
taught included the “What” skills, the “How” skills, Mindful Eating, Urge Surfng,
and Alternate Rebellion.

Vignette: Teaching Urge Surfng with a Malt Ball
T
h e r a p i sT
: Take one of the malt balls, if you would. But don’t eat it.

sa r a h: I’m so scared!

Th e r a p i sT: I know this is frightening. Although the urges feel overwhelming,
what is freeing about learning to Urge Surf is learning that you can have an
urge but not act on it.

sa r a h: I’m with you now and am OK, but what will happen once I leave the session? I’ll probably go out and binge!

Th e r a p i sT: You’re very worried, which is understandable. Take a few diaphragmatic breaths. What does your Wise Mind say about practicing this exercise?
sa r a h: Well ... my Wise Mind thinks it makes sense. But I’m worried about what’s
going to happen after the end of the session.

Th e r a p i sT: Let’s do this exercise now, and we’ll check in closer to the end of the
session to see how you’re doing. (Proceeds with Urge Surfng experiential exercise.)

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

Toward the end of the session, the therapist inquired: “Just checking in before
we end today’s session. Are you feeling any urges now to binge?”