Dialectical Behavior Therapy for Binge Eating and Bulimia (49 page)

Cl i e nT
3: Yes.

CoTh e r a p i sT
1: Great! (
Turns to next client.)
Cl i e nT
2: I’m committed to trying my absolute best to stop binge eating because
the consequences are so awful. But I know there will be times when I’ll
want the comfort of bingeing. To actually ask me to give that up is scary
because
no
one really has. It’s weird, to give something up that’s such a part
of you.

CoTh e r a p i sT
2: There are amazing benefts to stopping, but there’s no doubt it’s
scary to give up bingeing.

Cl i e nT
2: It’s so numbing.

CoTh e r a p i sT
2: Yes. As you sit here in this moment, can you say that you commit
to stopping binge eating?

Cl i e nT
2: Yes.

CoTh e r a p i sT
2: Great!

Cl i e nT
1: I have no idea how, but I’m willing to make the commitment!

CoTh e r a p i sT
1: That’s wonderful!

Cl i e nT
4: I feel like I’m totally committed, but I also stopped and had a very big
lunch before I got here just because I felt I would need something.

CoTh e r a p i sT
1: As you sit here in this moment, do you feel you can make the commitment?

Cl i e nT
4: Yes.

CoTh e r a p i sT
1: OK, great.

Session 2

As discussed in Chapter 3, a particular challenge of the group format involves
reviewing each client’s homework in a timely manner. Following are ways to address
the therapy-interfering behavior of clients who do not complete their homework for
various reasons.

Illustrative Case Examples

CoTh e r a p i sT
1: What we’d like to do is have each of you—for about fve to six min—

utes per person—take out your diary cards and tell us about your practice of

skills this past week. Mary [Cotherapist 2] will keep track of time. This week
that might include talking about renewing your commitment to stop binge eating or using the 3” × 5” card and really focusing on the negative consequences
of binge eating. Then give us the highlights of the chain analysis you flled out,
the key parts that you think are critical and that you’ll need to change in order
to stop binge eating. If you had any questions or problems flling this out, this
is the time to ask. If you didn’t complete the diary card or chain, we do ask that
you fll those out and turn them in during the break. So, who’s going to be the
brave beginner and start out?

Example 1: “I had ‘a week from hell.’”

Cl i e nT: I’m going to start off by using the excuse that this has been a week from
hell—but it really has! I haven’t done all of my homework, including not flling
out any days on my diary card. This is very important, I realize, but I didn’t
get to it.

CoTh e r a p i sT
1: Well, this is a good place to start, then. If you haven’t completed

your homework—whether because you didn’t understand it or didn’t get to

it—that’s going to interfere with your receiving the most beneft from treatment. As we talked about in the pretreatment orientation and again last
week, that’s the frst thing we have to address, even before focusing on stop—

ping binge eating. We’ve got to fgure out what you think is getting in the

way.

Cl i e nT: I didn’t fll it out at all last week so I don’t even know what exactly was
going on.

CoTh e r a p i sT
1: Let’s look at just one instance of not flling out your diary card,

say, at the end of yesterday?

Cl i e nT: Hmmm. Let me try to remember. Everything feels like such a blur. But
last night, I remember I was at work late and when I got home my kid was

needing a lot of attention. I didn’t take any time for myself to sit down and

fll out the diary card. I know it’s in my best interest to fll it out, but I just
didn’t.

CoTh e r a p i sT
2: My hunch is maybe that what you’re describing is a pattern, with

other demands interfering with what you think might be in your best interests.

Cl i e nT: It’s defnitely a pattern for me.

CoTh e r a p i sT
1: So if this is indeed a pattern, one possibility is that certain emotions, possibly such as resentment, would build up as a result. Feelings that

one might end up binge eating over. You put yourself off, put yourself off, put
yourself off ... until you’ve had it. Not knowing how to regulate those emotions,
you might end up relying on the binge to do it for you. Thinking about it now,
what skill or skills that we’ve taught so far could help you at that moment? If
you’re not sure, ask the group for ideas.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

Example 2: “I couldn’t face doing homework.”

Cl i e nT: I didn’t fll out my diary card because I just didn’t want to look at all this
stuff. It felt too painful!

CoTh e r a p i sT
1: This issue you’re bringing up is very important. New patterns,

such as putting yourself frst in your life or getting yourself to face something
you want to avoid—these are key if you’re to stop binge eating.

Cl i e nT: I agree. Oddly, for some reason I was able to look at it this morning, and it
wasn’t bad at all. I actually kind of enjoyed it. So now I actually feel like doing
it and regret that I didn’t before.

CoTh e r a p i sT
2: I can understand that regret. Maybe you feel like you missed out

on something, on discovering something about yourself?

Cl i e nT: Yes. But I didn’t want to know earlier.

CoTh e r a p i sT
2: One of the things you’re saying, and it really relates to what we

talked about last session, is that when your mood and your behavior are tightly

linked, if you don’t feel like doing something, you can’t follow through. Or,
if you experience an urge to binge, this would mean that you have to binge.

Regarding your homework, the question is how to manage the feelings of
embarrassment, of not wanting to look at something that happened that day

or something you did, while still following through on the behavior of complet—

ing your homework. We know that if you kind of give up and capitulate, you’re

opening yourself up to bingeing. Can you take a moment to think ahead to this

coming week? What skills would help you to keep your awareness and focus?

That’s really the purpose of the daily forms, to help you be aware of what is

going on.

Example 3: “I didn’t understand how to fll out the chain analysis.”

Cl i e nT: I got really confused and didn’t understand how to do the chain. This kind
of thing happens to me a lot. I look at things and think, “What am I supposed

to be doing?” I’m very good at talking about my feelings, but writing them

down is very diffcult for me. And if I don’t know, I deal with it by just closing
the book.

CoTh e r a p i sT
2: OK .
.. it’s diffcult but it is not impossible. One of the things that

I think that you’re describing, and we’ve seen in some other contexts, too, is

capitulating. I’m just guessing, but there’s probably some sort of judging about
“Oh gosh, I can’t fgure this out exactly, I can’t do it perfectly.” Or maybe that
it’s too much, you won’t be able to fnish it all. So to manage the anxiety, you

close the book and don’t do any of it. I think you become overwhelmed by the

judging.

Cl i e nT: I can fll out the diary card boxes daily. That seems more straightforward.

But looking at the chain, I just think, how do I do this?

CoTh e r a p i sT
1: You were able to do the diary card daily, that’s terrifc! And what

you’re doing right now is identifying some of the links that interfered with

your flling out the chain. We are going to practice flling out the chain analysis later today in group, which should help. But I think one of the things that

Illustrative Case Examples

will be important for you is not to give up or expect that you will do it abso—
lutely correctly, or that there even is a “right” or “perfect” way. Try to work
with the chain as best you can. Break it into small blocks and tackle one block
at a time. Even if you fgure out a piece of it, complete one link or one of the
boxes, that’s a signifcant start.

Example 4: “I’ll start to want to eat.”

Cl i e nT: I looked at the blocks on the chain and said, “I can’t do it. I’m just too overwhelmed. I’m going to start to want to eat.” So I said, “forget it, I just won’t do
it.” I sat and just relaxed. I said, “OK, I haven’t done it. If they drop me out of
the group, so be it.” When I get overwhelmed I have to put whatever it is away
and just take a deep breath.

CoTh e r a p i sT
1: That can certainly be a very skillful thing to do. If you feel that
your emotions are starting to become overwhelming or if they are building, it
is very skillful to stop for a moment and take a rest. A key is to try to take a
step back and center yourself with your breathing. We’re going to talk more
about that very skill today. The idea is that stepping back can actually help
you fnd a way to do what would otherwise be overwhelming. You can maintain
awareness without being fully caught up in your emotions.

Cl i e nT: I guess one thing I could do is to look at it again, after I’ve stopped and
breathed.

CoTh e r a p i sT
2: That makes sense—to check back in with yourself and, when you
are ready, look at just one block, staying in close contact with yourself so you
don’t push yourself too hard.

Cl i e nT: I think I could.

In Session 2, the concept of dialectical abstinence was taught. The following
vignette of an interaction between a group member and cotherapist highlights how
the concept of dialectical abstinence can be applied.

Cl i e nT: Having binged “big time” today at an event I ran at work, I’m thinking it’s
too simplistic to think I can sit here and say to myself “I’m committed.” I know
there are skills you’ll be teaching us, but I need to have those skills already so
I’d know my commitment would have something to underpin it.

CoTh e r a p i sT: Does it have to? Does a commitment have to be the same thing as
the behavior? In other words, could you be committed to something wholly
and not necessarily have the confdence that you could do it, not yet have the
evidence that you could?

Cl i e nT: You could, but I always measure my commitment by my success. I’m
achievement oriented.

CoTh e r a p i sT: Think about the metaphor of Olympic athletes we were just talking
about. Before they start the race, they are fully dedicated to going all out for
the gold. If, after the race is over, they don’t win it, then they deal as skillfully
as they can with that. But when you’re going for it, it can’t be in your mind that
“I can’t say I’m committed to it because if I fail, then I’ll be mad at myself” or

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
“I probably can’t really do it” or “It’s OK if I don’t really do it.” What we’re say-ing is that it’s important to your success to be able to hold two different things
in your mind at the same time. One is the 100% commitment to yourself and
to stopping binge eating. The other, which is not at the forefront of your mind,
is the knowledge that if you do binge, you’ll deal with it without beating yourself up. You’ll pick yourself up, you’ll learn from it, you’ll say, “It’s hard, I just
started this program. I don’t have all the skills yet” and then you’re right back
with “I’m 100% committed.” This is dialectical abstinence.

Cl i e nT: I can catch a glimpse of what you’re talking about when you put it that
way.