Dialectical Behavior Therapy for Binge Eating and Bulimia (50 page)

CoTh e r a p i sT: Great!

Core Mindfulness Module: Sessions 3–5
Urge Surfng

Though we have not had it occur often, sometimes a group member becomes emo—
tionally dysregulated during the Urge Surfng exercise. Therapists can use this
as an important opportunity to help the client to identify and practice her or his
Emotion Regulation skills during the session.

CoTh e r a p i sT: Would someone like to describe what it’s like to Urge Surf with this
malt ball?

Cl i e nT
1: (
Starts to cry.) It’s just too hard.

CoTh e r a p i sT: I can really hear how upset you are (gently). Can you describe to me
what emotion you’re feeling right now?

Cl i e nT: All I can think about is binge eating. I’m okay while I’m here in the group
but I’m upset because ... (sobs) ... after the session I’m just going to end up in
the grocery store, and I’ll buy more malt balls and more food. Maybe you had
your reasons, but this was a terrible day for me to practice Urge Surfng. I wish
I hadn’t come to group.

Cl i e nT
2: I think this should stop. Can’t you see she’s really upset?

CoTh e r a p i sT: (Acknowledges that Client 2 has spoken but addresses Client 1
.) I

know that you’re feeling really distressed and wish you hadn’t come to group
today. Is that what you’re feeling right now?

Cl i e nT
1: (
Gulps and nods.)

CoTh e r a p i sT: Maybe you could begin by taking a couple of breaths and just observe
the sensations in your body.

Cl i e nT
1: I shouldn’t cry in group.

CoTh e r a p i sT: That sounds like a judgment, not a sensation (teasingly). Judgment
duly noted, thank you for sharing.

Cl i e nT
1: (
Small giggle.
)

CoTh e r a p i sT: OK, just let the judgment go. And tell me what you notice in your
face, your chest. ...

Illustrative Case Examples

Cl i e nT
1: I can feel tears on my face, and they are wet. My chest is heavy.
CoTh e r a p i sT: What are the thoughts and feelings that you’re having right now?
Cl i e nT
1: I’m upset at myself for being upset right now in group. My husband
always says I get upset too much and he can’t cope with my feelings. I get too
angry, too upset. Why can’t I be normal?

CoTh e r a p i sT: (Gently but in a focused way.) So what are your emotions right
now?

Cl i e nT
1: I feel humiliated for crying in group.

CoTh e r a p i sT: You mentioned an urge to go to the store after group to binge. What
emotion do you think might be connected to that urge? Maybe anger at us for
choosing to have you practice Urge Surfng today?

Cl i e nT
1: Well, right now I don’t feel that any more. I just feel embarrassed.
Cl i e nT
2: I think you’re showing heaps of courage in talking about how you’re feeling right now.

Cl i e nT
1: I didn’t feel like I had much choice, but thanks.

CoTh e r a p i sT: So where is the urge to binge after group right now?

Cl i e nT
1: It’s less. I think I can go on now.

Alternate Rebellion (Session 5)

Alternate Rebellion uses the Mindfulness “How” skill of Effectively to satisfy a
client’s wish to rebel without destroying her or his overriding objective of stopping
binge eating. Although clients with BED relate easily to the concept behind the
skill, we have found that they beneft from being given specifc examples of how
other clients from prior groups have put it into use.

CoTh e r a p i sT: “We really encourage you to be creative in using this skill. For
example, some prior group members who felt judged by society for being over—
weight have ‘rebelled’ by buying a dessert, such as a single-serving ice cream
cone, and eating it in public—in full view. Others have bought and worn beau—
tiful lacy lingerie. One client was angry at her husband for buying doughnuts but not eating them himself. She poured salt on them and threw them in
her backyard pool! (Group members laugh.) What are some ideas you have for
using this skill?”

Emotion Regulation Module: Sessions 6–12

The following vignette illustrates the application of opposite action with a client
who says he is feeling hopeless about treatment and does not want to practice the
skills.

Cl i e nT
1: These skills don’t work, and I don’t think this treatment works. I’ve been
coming here for almost three months, and last night I got into a big fght with
the wife and downed a dozen doughnuts.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
CoTh e r a p i sT
1: When I hear doughnuts, I hear the opportunity for opposite
action!

Cl i e nT
1: (
Laughing and groaning) I knew you’d say something like that.
CoTh e r a p i sT
1: I’m not saying that I don’t hear how discouraged you are.
Cl i e nT: Yeah—I’m feeling hopeless. When I feel like this, I don’t feel like practicing the skills or even coming here.

CoTh e r a p i sT
1: How great that you practiced opposite action in coming here today.

How can you practice opposite action next time you’re faced with a fght with
your wife and a dozen doughnuts?

Cl i e nT
1: What was the skill I practiced to get here today again?

CoTh e r a p i sT
2: (
Laughing) Hey, who remembers opposite action?

Cl i e nT
2: Opposite action is when you act opposite to the urge that goes with your
emotion. It’s good for when you want to change your mood. If you’re depressed
and your urge is to skip group and stay in bed, for example, acting opposite
means getting out of bed and coming to group.

Cl i e nT
1: Oh, yeah, that’s what I did today to get here! But when I’m angry at the
wife, opposite action would mean practicing being nice even if I have the urge
to yell.

CoTh e r a p i sT
2: Right on!

Cl i e nT
1: (
Laughs.) Well, it would have a better chance of helping than what I
did!

CoTh e r a p i sT
1: So do I have your commitment to practice this skill this week,
whether or not you get in a fght, so you’re ready in the future?

Cl i e nT
1: Can do.

Distress Tolerance Module: Sessions 13–18

The discussion of Radical Acceptance in a group session in particular can be diff—
cult when clients challenge the skill by asserting that certain things are too awful
to be accepted.

Cl i e nT: Radical Acceptance doesn’t make sense for me.

CoTh e r a p i sT: In what way don’t you think it makes sense for you?

Cl i e nT: Because it means that if something awful has happened, then I have to be
all OK about it. And there are some things that are too terrible to ever forgive.

My mother gave me up to foster care, and I was treated terribly—I told her, but
she didn’t do anything. I can’t forgive her for what she did to me, and I think
about it all the time because it ruined my life.

CoTh e r a p i sT: I’m so sorry that happened to you. You’re making a really impor-tant point that we need to make sure is clear. Radically accepting something
means accepting that a reality has occurred and recognizing its consequences.

It doesn’t require that you forgive your mother. Forgiveness is a choice and
not a necessary outcome of Radical Acceptance. Practicing Radical Acceptance

Illustrative Case Examples

can help you deeply accept your emotions about your childhood. Then you can
choose or not choose to forgive your mother. You might want to forgive if these
emotions interfere with your quality of life. But a perfectly productive life is
possible through Radical Acceptance without forgiveness. To deal with suffering, acceptance is all that’s needed. Sometimes, just accepting your feelings as
they are can make the suffering less.

Review of Skills and Planning for the Future: Sessions 19–20

In the last session, therapists had each group member read from their homework
regarding their plans for the future.

CoTh e r a p i sT
1: What are your plans for making sure that you practice the skills
that have been so helpful to you?

Cl i e nT: I’ve made mini-copies of the diary card so I can carry it around in my
purse. I’ve also gotten a new cover for my notebook with all my skills—bright
red! So it will be really easy for me to spot!

CoTh e r a p i sT
1: Wow—that’s great. Tell me one diffcult situation that kept com-ing up on your chains and what skills you will use to deal with it without using
food.

Cl i e nT: I have the strongest urge to binge after dinner parties. I tend to skip most
of the yummy foods when I’m there, like dessert, for instance, because I think
I’m still overweight. But I get resentful when I leave and end up stopping at the
grocery store. The skill I’ve gotten the most help from is Mindful Eating. I just
need to remember to use it—that it’s not the particular food that is a problem
but using food to push down my feelings. Food itself is fne, and I can enjoy it
for what it is I when I eat mindfully.

CoTh e r a p i sT
1: That’s terrifc! Who would like to share next?

As noted in Chapter 7, group members often wish to mark the end of group
with a ritual of some sort. We encourage group members to select a ritual they
think most appropriate. In addition, we often distribute a list of quotes about emotions (Appendix 8.1).

APPENDIx
8.1

Quotes about Emotions

Accepting does not necessarily mean “liking,” “enjoying,” or
“condoning.” I can accept what is—and be determined to evolve
from there. It is not acceptance but denial that leaves me stuck.

—naTh a n i e l
B
r a n d e n

But are not this struggle and even the mistakes one may
make better, and do they not develop us more, than if we kept
systematically away from emotions?

—Vi nCe nT
Va n
G
o
Gh

Let’s not forget that the little emotions are the great captains
of our lives and we obey them without realizing it.

—Vi nCe nT
Va n
G
o
Gh

One’s suffering disappears when one lets oneself go, when one
yields—even to sadness.

—a
n
To i n e
d e
sa i nT-ex u p é r y

(translated from French by Curtis Cate)

Plenty of people miss their share of happiness, not because
they never found it, but because they didn’t stop to enjoy it.

—Wi l l i a m
F
e aT
h e r

The impossible can always be broken down into possibilities.

—auTh o r
un k n oW
n

Once we accept our limits, we go beyond them.

—B
r e n d a n
F
r a n
C
i s

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
9

Future Directions

T
his chapter outlines several future directions for DBT for BED/BN. Our aim
is to be expansive. While fully acknowledging the limited database from clinical
trials, we believe it worthwhile to think more broadly about the implementation
of DBT for eating disorders for future clinical and research endeavors. We frst
discuss modifcations to the treatment for those working with adolescent clients.
Second, we focus on reducing the risk of relapse after the formal end of treatment
and enhancing the likelihood of maintaining abstinence. Third, we address includ—
ing weight loss as a treatment target when working with obese clients. Fourth, we
consider providing time-limited DBT for clients who have BED/BN and are concur—
rently being treated by clinicians without a background in treating eating disorders. Finally, we explore improving the cost-effectiveness of DBT for BED/BN.