Dialectical Behavior Therapy for Binge Eating and Bulimia (51 page)

WORKING WITH ADOLESCENT CLIENTS

Of relevance, adolescents with suicidal behaviors have been shown to be develop—
mentally capable of responding to modifed versions of DBT for BPD (Miller, Rathus,
& Linehan, 2007). Given the lack of empirically supported treatments available for
adolescents with eating disorders, it is important to investigate adapting existing
treatments for adults with eating disorders to younger populations. Frequently,
the frst signs of an eating disorder become apparent during adolescence. Additionally, adolescence is synonymous with emotion dysregulation!

To date, limited preliminary evidence suggests that DBT for eating disorders
can be usefully adapted for adolescents (Safer, Couturier, & Lock, 2007; Salbach-Andrae, Bohnekamp, Pfeiifer, Lehmkuhl, & Miller, 2008). Recently, Salbach-Andrae and colleagues (2008) described a case series of adolescents with anorexia
and bulimia treated with 25 weeks of twice-weekly DBT (i.e., individual therapy
and group skills training). Signifcant posttreatment improvements in eating-disorder behaviors and psychopathology symptoms were reported (Salbach-Andrae

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

et al., 2008). In an earlier case report, Safer, Couturier, and Lock (2007) modifed
DBT for BED for a 16-year-old female binge eater. Their adolescent version of DBT
for BED retained the majority of the treatment elements presented in this book’s
earlier chapters. For example, the behavioral chain analysis and diary card were
unchanged. In addition, the format of sessions included homework review in the
frst part of the session, followed by the teaching of new skills. At the same time, as
described next, a number of adolescent-specifc modifcations were introduced.

Modifcations to the Introductory Sessions

The therapist met conjointly with the client and her parents for the frst 15 minutes
of the initial treatment orientation session, followed by a private meeting with the
client. This provided an opportunity to introduce the parents and the client to an
overall orientation to the DBT model, its goals, and the structure of treatment.
Furthermore, it allowed discussion of the parents’ role in treatment. Parents were
told their responsibility would be to support their daughter as she attempted to
generalize what she learned in therapy into her life, including her interactions
with the family. If it became apparent that the parents could play a more direct
role and that the client would like their help, the parents would be invited to attend
sessions (lasting 30–60 minutes) following the patient’s individual sessions. The
specifc number of these sessions would be decided based on clinical judgment.
During those sessions, the client would be invited to teach her parents the skills
she was learning in therapy, working with her parents to identify specifc ways in
which they could help her manage her feelings and behaviors more effectively.1

Modifcation to Distress Tolerance Skills: Sessions 2–5

Another modifcation used in this case report included changing the sequence of
the skills taught. Distress Tolerance skills were introduced frst based on the prac—
tical and concrete nature of these skills, felt to be more easily understood and uti—
lized by adolescents and more likely to maintain their interest in treatment.

Modifcations to Mindfulness Skills: Sessions 6–10

Extra sessions were added to this module based on experiences noted by Miller and
colleagues (2007) in their work using DBT with suicidal adolescents. The concept
of accessing one’s Wise Mind can be challenging for adolescents, whose develop—
mental stage includes identity formation and emotion identifcation. To address
this challenge in DBT for BED/BN for adolescents, simpler, less abstract defni—
tions were used to convey the Mindfulness concepts than those used with adults.
Wise Mind was referred to as one’s deepest “gut feeling” about the truth of the situ—
ation, and Emotion Mind as that “part of your mind whose advice totally depends
on your current mood” (e.g., deciding that “I need a snack” must be the right course
1Whether the parents require separate skills training or are taught any necessary skills by the adolescent
during the family session would be determined on a case-by-case basis.

Future Directions

of action when faced with a diffcult homework problem instead of checking in more
deeply with one’s mind and body about what would truly be effective).

Alternate Rebellion was not modifed for adolescents, though it is worth high—
lighting this skill’s particular salience for this population, many of whom are
gradually exploring more independent thought processes and action patterns. This
involves emphasizing the purpose of the skill, to fnd effective, adaptive means
of regulating diffcult feelings. Examples of ways adolescents may fnd it useful
to practice Alternate Rebellion include the use of dress or fashion (e.g., by paint—
ing fngers with garish nail polish, wearing loudly clashing colors, or redecorating
their bedrooms).

Modifcation to Emotion Regulation Skills (Sessions 11–17)
A modifcation for adolescents in this module involved making the Adult Pleasant
Events Schedule in the Linehan (1993b) skills manual relevant to teenagers. Items
such as “thinking about retirement” were eliminated, and activities relevant to
teens, such as “planning fun things to do during summer vacation,” were added.

Addition of Interpersonal Effectiveness Skills (Sessions 18–21)
Interpersonal dilemmas are often of paramount importance to teens, and build—
ing mastery in this area is a typical goal of adolescent development. Therefore, it
seemed important to add this module when modifying the manual for adolescents.
(Decreasing the number of review sessions allocated allowed the total number of
sessions to be only slightly increased by this additional module, from 20 to 21.)
Though it provided only preliminary corroboration for this modifcation, it is of
interest that the client in the case report noted this module to be her most useful.

The interpersonal effectiveness skills, including focusing on the different types
of desired outcomes (e.g., achieving one’s objectives, preserving the relationship,
maintaining self-respect), were taught and rehearsed using relevant age-appro—
priate scenarios (e.g., requesting permission to attend a sleepover birthday party,
obtaining parental permission to stay out late with friends).

Other Modifcations for Adolescents

Homework was more frequently tackled collaboratively during sessions, at least
initially. This was done to ensure understanding of the key concepts and to be
considerate of academic demands on an adolescent attending school. Also, because
adolescents are often hesitant to initiate calls to adults, the modifed treatment
involved scheduling between-session phone calls (so that the therapist expects the
patient’s call) and encouraging e-mail. Appropriate self-disclosure about the therapist’s use of the skills in his or her life, as in DBT for BED/BN (and, of course,
standard DBT) is always useful, but especially so with adolescents in lessening the
adult–teen power differential and strengthening the alliance. Finally, role play—
ing, with the therapist and patient switching roles, was an effective way for both
patient and therapist to better appreciate the presence of differing points of view.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Familial Modifcations

The most marked of the adolescent-specifc modifcations utilized by Safer and colleagues (2007) was the inclusion of family sessions as needed. In the case report
(Safer et al., 2007), for example, 4 of the 21 sessions were expanded (by an extra
30–60 minutes) to include the adolescent’s family. The justifcation was the consis—
tent identifcation, via the chain analyses, of the client’s sense of academic pressure
being a trigger for her binge eating. Both the client and her family were highly
achievement oriented, which is common in individuals with eating disorders.
Bringing the subject of achievement into the open during family sessions, while
also targeting it individually, allowed identifcation of a key dialectic for the family: accepting the teen just as she was while simultaneously wanting her to be as
successful as possible. The client’s perspective was validated, and she was encour—
aged to communicate more effectively with her parents about their expectations.
This key dialectic is likely of relevance to other families with adolescents suffering
from eating disorders. The client decreased her fears of failure without lowering
her standards.

Interestingly, the use of the family as reinforcing agents appeared to be the
most effective of the various interventions in the piloted case example. This may
imply the existence of a common theme for parental involvement within treatments
for adolescents with eating disorders, as suggested by the evidence pointing to
the superior outcomes of family-based treatments for anorexia nervosa for those
patients whose illness began before age 19 (Eisler et al., 1997; Robin et al., 1999;
Russell, Szmukler, Dare, & Eisler, 1987).

IMPROVING MAINTENANCE OF ABSTINENCE/REDUCING RISK OF RELAPSE

Telch and colleagues (2001) reported a decrease in abstinence after DBT for BED,
from 89% at posttreatment to 67% at 3-month follow-up to 56% at 6-month follow-up.
In examining DBT for BN, Safer and colleagues (2001b) found that the frequency
of binge eating and purging increased from posttreatment to 3-month follow-up.
Clearly, the issue of improving maintenance among those initially responsive at
posttreatment is important.

The following suggestions are as yet without empirical support but are pre—
sented as options for clinicians concerned about reducing relapse among clients
who have received DBT for BED/BN treatment. These suggestions include (1) add—
ing booster sessions; (2) providing online support; (3) offering ongoing advanced
DBT for BED/BN groups; and (4) combining DBT with CBT or IPT.

Adding Booster Sessions

Clients may beneft from additional “booster” group sessions to aid in maintain—
ing treatment gains made during therapy. The necessary frequency of such sessions is unclear. Because relapse in the Telch
et al.
studies (e.g., 2001) has been
documented by the 3-month follow-up assessment, booster groups should likely

Future Directions

begin meeting well before this point. Perhaps such groups might meet monthly,
then bimonthly, decreasing in frequency over time. These sessions would focus on
any problematic behaviors that clients have experienced occurring since their last
meeting.

Rather than offering group sessions, another means of improving maintenance
could include the option of treating clients individually after the completion of
group treatment. A number of our clients have requested this, and in nonresearch
settings it may be desirable for a number of reasons. Clients may feel that the
group format moved at a pace ill suited to them and that they would beneft more
from one-on-one treatment. Our experience is that some clients do indeed have dif—
fculty making use of the group time. A stepped-care-type approach might involve
identifying such clients during the group and offering them a course of individual
treatment, with the possibility of rejoining a group that forms at a later time. The
individual-session format may also be useful for clients who no longer have diffcul—
ties with binge eating but wish to apply their newly acquired emotion regulation
skills to other quality-of-life targets (e.g., increasing their social support, starting
to date, taking up new interests).

Providing Online and/or CD-ROM Support

Another option to improve treatment gains includes the development of support
online and/or via CD-ROMs. Support might involve online chats between group
members (possibly moderated by coleaders) and/or having group members fll out
and submit online diary cards and chain analyses between group sessions while
treatment is under way or as part of a booster session package. Other options
include using personal digital assistants (PDAs) as a means of tracking. Prelimi—
nary fndings for such innovative methods have been positive. For example, CBT
for BED delivered by CD-ROM was reported to be a well-accepted and effective
treatment modality (e.g., Shapiro et al., 2007). And in a study examining the role
of Internet support versus face-to-face support in the maintenance of weight loss,
no signifcant differences in weight loss were found (Harvey-Berino, Pintauro, Buz—
zel, & Gold, 2004).