Dialectical Behavior Therapy for Binge Eating and Bulimia (47 page)

sa r a h: Yes! I’m a 6 out of 6 on my urges to binge scale!

Th e r a p i sT: At this moment your urges are really strong. OK. What skills can you
practice to manage these urges to binge?

sa r a h: I guess I could sit outside in the waiting area and practice Urge Surfng
and not leave the waiting room till my urges are reduced.

Th e r a p i sT: That sounds good. Sometimes it takes longer than the time we have
together in session for urges to decrease.

sa r a h: My urges had decreased earlier but just went up when I realized the session was about to end.

Th e r a p i sT: Anything that might interfere with this plan?

sa r a h: Well—I might have to leave to pick up my kids before my urges go down.
Th e r a p i sT: If that were to happen, what skill could you practice?

sa r a h: Well, I could practice Mindfulness while I am at stoplights, Observing and
Describing the steering wheel and how it feels in my hands.

Th e r a p i sT: That sounds like a great solution. Do you think you can be committed to our plan—sitting in the waiting room till your urges go down, and then
practicing Observe and Describe with the steering wheel at stoplights should
you have to leave early?

sa r a h: I’m committed to our plan.

Vignette: Teaching Alternate Rebellion

Th e r a p i sT: I’m very excited to teach you this next skill because I think you’ll fnd
it particularly helpful at night, when you’ve described having lots of urges. It
is called Alternate Rebellion. (Explains the concept of alternate rebellion and
then continues.) How do you think binge eating and purging may be a form of
rebellion for you?

sa r a h: Oh, I’m not the rebel type!

Th e r a p i sT: I hear you, but just go with me on this. I could be wrong, but I noticed
you typically start having urges to binge at night when you’re alone with the
kids because Dave’s still at work. The kids are making demands on you—
they want dinner, they want help with their homework, they can’t fnd their
clothes for soccer practice tomorrow, and so on. I think anyone under the cir-cumstances would feel just an itsy bitsy feeling of resentment, just a wee bit of
feeling grumpy and annoyed, just even a little bit (smiling)?

sa r a h: Well ... maybe. I hate to think of myself being like that, but I think it’s
probably true. Sometimes I just want to run away from it all.

Th e r a p i sT: How could you honor that very legitimate wish in a way that, unlike
binge eating and purging, wouldn’t harm you? Think of all the possibilities,
even the wildest ones!

Illustrative Case Examples

sa r a h: I guess I could get some babysitting help. When I’m really stressed I could
give up trying to push the homework till I felt better and instead watch a video
with the kids.

Th e r a p i sT: Great! Anything even more wild?

sa r a h: I could have a juice spritzer with one of those paper umbrellas in it (laugh-ing). I could read a celebrity magazine. Now that I think of it—it all sounds
pretty good.

Th e r a p i sT: These are excellent ideas for Alternate Rebellion! So what I’m understanding is that you turn to bingeing and purging to manage feeling stressed
and maybe even the smallest bit (smiling) resentful. And in the short term it
helps. But by practicing Alternate Rebellion, you are honoring your feelings
and the urges to rebel and take care of yourself, but you do so without the lon-ger term guilt and shame that your bingeing and purging is causing.

Emotion Regulation Module: Sessions 6–12

By the sixth session, Sarah reported having stopped engaging in large binges and
compensatory purges. She still struggled, however, with smaller binges (i.e., sub—
jective binges). The goals of this next module are to teach the client how to iden—
tify and label her or his emotions, understand the function of her or his emotions,
reduce her or his vulnerability to intense emotions, increase the number of positive
emotional events, increase mindfulness of emotions, and learn to change her or his
emotional experience when possible.

In discussing the model of emotions (Chapter 5, Appendix 5.2), Sarah said that
she did not think that emotions sometimes really played a role in her urge to vomit—
it was more the physical discomfort of having food in her stomach. Sarah’s focus on
physical rather than emotional sensations is typical of many bulimic clients.

sa r a h: Like I was saying, I don’t think any emotions are involved sometimes. I just
feel physically uncomfortable—I can feel
the bagel just sitting in my stomach,

not moving! This model of emotions doesn’t make sense when what’s going on
is purely physical.

Th e r a p i sT: But in your voice I hear something more.

sa r a h: It just feels gross and lumpy, and it makes my tummy stick out. But that’s
a physical thing.

Th e r a p i sT: Hold on (smiling). I hear a judgment in the word “gross.”

sa r a h: Well, it just embarrasses me that my stomach is so poochy.

Th e r a p i sT: Aha! Embarrassment is an emotion.

sa r a h: But I’m not just embarrassed. It’s really very uncomfortable.

Th e r a p i sT: Let’s look again at this model. Can you see how the event was eat-ing the bagel and that, following this, the interpretation was “My stomach is
gross”? This is associated with changes in your brain and body, and you fnd
yourself focusing on those sensations and the interpretation again and again.

All those are part of the embarrassment that you are describing, which starts

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
to include shame. This is a great example of how emotions, such as embarrass-ment and shame, loving themselves, fre and refre again and again.
sa r a h: Well, I guess that could be true. Some days, such as when I’m busy, I don’t
even notice what my stomach feels like when I’ve had a bagel.

In Session 8 the therapist discussed with Sarah the various functions of emotions. The therapist asked: “Based on what we’ve been talking about, how has
binge eating and purging interfered with the natural function of your emotions?”

sa r a h: Well, I don’t know, really.

Th e r a p i sT: One thing I have noticed is that you’ve mentioned that everyone around
frequently comments on how “together” you are and how you seem to be able to
do it all so effortlessly. Even my experience working with you is that it is hard
for you to let me know that things are not as together as they seem.
sa r a h: That is true—but people don’t know the real me.

Th e r a p i sT: It sounds as though you’re on to something—that your binge eating
and purging allow you to keep a happy face on so that people don’t know the
real you and the struggles that you have in juggling everything.

sa r a h: I think that’s true. And I don’t want to use the binge eating and purging
any more—the cost is too high.

In Session 9, as part of the discussion of vulnerability to Emotion Mind, the
topic of balanced eating was brought up. One way that this adapted version of DBT
differs from other treatments for eating disorders, such as CBT, is that it contains
no behavioral focus on the pattern of eating. According to CBT’s dietary restraint
model, restriction of food leads to binge eating and purging. In DBT, hunger (or
imbalanced food intake in general) is understood as increasing one’s vulnerability
to Emotion Mind but not as a prompting event per se.

Th e r a p i sT: Does imbalanced eating make you more vulnerable to your Emotion
Mind?

sa r a h: I try to eat healthily.

Th e r a p i sT: You do! One thing I’ve noticed from your recent chains is that you’re
likely to describe urges to binge while making dinner, especially if dinner is
being prepared late.

sa r a h: That’s true. Evenings are a very busy time, with getting the girls fed, dinner made, and just dealing with the end of the day. If I’m too hungry on top of
everything, I’m a lot more likely to feel overwhelmed and feel like bingeing.
Th e r a p i sT: So, what could you do differently, based on your Wise Mind?
sa r a h: Well, I guess not to ever get too hungry, especially not leaving dinner till
really late.

Session 9 also involved discussion of Sarah’s ratio of positive to negative experiences. The issue of hunger was brought up again. The focus was on emotions,

Illustrative Case Examples

with hunger (or food restriction) understood as a means of Emotion Regulation.
For example, Sarah recognized that one of the ways she tried to generate a positive
emotional experience, especially on very stressful days, was by staying hungry as
long as she could because this felt “virtuous” and “good.”

Th e r a p i sT: Staying hungry appears to be a way of trying to regulate your emotions (with teasing tone). How could “staying hungry” not be on this pleasant
events list? (Waves handout back and forth.)

sa r a h: (Laughs.) I guess it’s probably not there because it doesn’t always work that
well.

Th e r a p i sT: In what way?

sa r a h: Well, it makes me more crabby. I also notice I can’t think very well because
I feel so hungry.

Th e r a p i sT: Do you think that eating as little as possible, just like purging, is an
attempt to distance you from your emotional experiences of the day? From
what I hear, I notice that you don’t end up doing many pleasant activities dur-ing a day that are just for you. So instead of observing the emotions that you
are experiencing over a day, your mind is focused on how little you have been
eating.

sa r a h: I wish it weren’t true, but that makes sense.

In Session 11, the therapist and Sarah reviewed the myths about emotions.

Th e r a p i sT: Which myth about emotions do you fnd most diffcult to challenge?
sa r a h: “Letting others know that I am feeling bad is weakness.”

Th e r a p i sT: (with teasing tone) Yes, asking your husband to unload the dryer maybe
once a year to help you out a bit. That would be really weak!

sa r a h: (Laughs.) Oh, asking Dave to unload the dryer once in a while wouldn’t
show him I’m weak. But I see what you’re getting at. Maybe telling Dave about
how stressed I am and how I need his help once in a while isn’t such a sign
of weakness. I like feeling like my needs are legitimate—it feels better than
binge eating and purging to try to get rid of them.

Distress Tolerance Module: Sessions 13–18

During this third and fnal module, Sarah was taught Distress Tolerance skills
(Acceptance skills and Crisis Survival skills) to help her tolerate painful emotions
when distressing situations and circumstances took place that could not be changed
in the moment. The Acceptance skills emphasize accepting one’s current situation
and emotional state from deep within. They include Observing Your Breath, Half—
Smiling, using Awareness Exercises, and Radical Acceptance—which contains
Turning the Mind and Willingness). The Crisis Survival skills involve the strate—
gies of Distracting, Self-Soothing, Improving the Moment, and deliberate consid—
eration of the Pros and Cons of either tolerating the distress or using maladaptive
behaviors such as binge eating and purging.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
In Session 16, the therapist presented the skill of Burning Your Bridges by
leading Sarah in an experiential exercise. Sarah did not have diffculty deciding to
burn her bridge to binge eating. She had ceased binge eating and purging for the
preceding 10 weeks. Especially for those clients who may not have stopped by this
point, the skill of Burning Your Bridges can be just what is needed to motivate a
client to do so, making use of the fact that one more month of treatment remains
(as per our research protocol of 20 sessions).

For example, consider another client, who was still struggling with binge eating and purging at this stage. She is asked whether she feels ready to burn her
bridges to Binge Eating Island as a strategy to stop binge eating.