Dialectical Behavior Therapy for Binge Eating and Bulimia (52 page)

Offering an Ongoing Advanced DBT for BED/BN Group

Maintenance might also be improved by offering clients an advanced DBT group
after they have completed the 20-week DBT for BED/BN program as described.
Rather than holding monthly booster sessions, this advanced group might meet
weekly. Attendance could be allowed on a drop-in basis or through requiring com—
mitment to a designated block of sessions.

Combining DBT with CBT or IPT

Given the different mechanisms hypothesized to underlie CBT, IPT, and DBT for
BN or BED, research combining these treatments may enhance maintenance.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

WORKING WITH OBESE CLIENTS
WHO HAVE BED—ADDING WEIGHT LOSS AS A TARGET

The DBT for BED and BN treatment as described focuses on helping clients achieve
abstinence from binge eating, not on weight loss. After 20 sessions of DBT for BED,
for example, clients had not lost signifcantly more weight than those assigned to a
wait-list condition (Telch et al., 2001). The lack of infuence on weight is consistent
with that found in other BED treatments (e.g., Wilfey et al., 2002).

Numerous BED treatment studies have also indicated that participants who
maintain abstinence from binge eating after treatment lose more than those who
relapse (e.g., Agras, Telch, Arnow, Eldredge, & Marnell, 1997). Among clients with
BED treated in the Telch
et al.
(2000, 2001) studies, for example, the mean weight
loss after 20 group sessions was 4.2 pounds. At the 6-month follow-up assessment,
those who maintained abstinence had lost an additional 7.2 pounds compared with
an additional 1.5 pounds lost for those who relapsed (Safer, Lively, Telch, & Agras,
2002).

Given the prevalence of overweight and obesity among BED clients and the
concomitant health concerns, the question of how to help such clients lose weight
is of great signifcance. DBT for BED/BN, with its emotion regulation focus, might
offer a unique option for obese clients if its skills were adapted to target the types
of emotional dysregulation that lead clients to break their diets, to drop out of
weight management and exercise programs, or to avoid weight loss attempts alto—
gether. The suggestions (e.g., adapting the targeted problem behavior, combining
DBT with other weight management treatments) offer preliminary directions for
how such a weight management treatment might proceed when undertaken after
the achievement of binge abstinence.

Adapting the Targeted Problem Behavior

As noted, DBT for BED/BN primarily targets reducing emotional eating behaviors
such as binge eating, not reducing body weight. In other words, therapists would
not label the consumption of high-calorie foods as a problem behavior if such foods
were eaten mindfully and with control.

A weight-loss-oriented adaptation would include adapting the path to mindful
eating (Chapter 3, Appendix 3.2). By adding additional targets, such as deviating
from one’s weight loss plan through overeating, high-calorie food choices, or physical inactivity (Figure 9.1), clients can conduct chain analyses on these behaviors.
Such chain analyses would identify the particular emotions leading to lapses from
the client’s food plan. For example, if a client said he or she overate because he or
she felt “deprived,” the associated emotions and thoughts could be fully observed
and described. This might involve observing the thoughts “The amount of food on
my plate won’t be enough” or “I won’t be able to bear the hunger,” accompanied by
potential emotions such as fear or resentment. For clients who avoid engaging in
physical activity because of shame, chain analyses could be used to explore what
skills (e.g., opposite action) could be used in these situations.

Future Directions

1.
Stop any behavior that interferes with treatment.*
2.
Stop binge eating—eating large or small amounts of
food while experiencing a sense of loss of control.
3.
Stop other problem behaviors—overeating, eating
off plan, mindless eating, not exercising.

4.
Decrease cravings, urges, preoccupation with food.
5.
Decrease capitulating—that is, closing off options to
not binge eat.

6.
Decrease apparently irrelevant behaviors—for
example, buying binge foods “for company”;
scheduling a phone call during your exercise time.

FIGURE 9.1.
Treatment targets. *Though not explicitly delineated in this model, decreasing any
life-threatening behaviors takes precedence over the other targets, just as in standard DBT, if
crises arise.

Combining DBT with Other Weight Management Treatments
DBT may be effectively combined with other weight management treatments such
as bariatric surgery, BWL (including self-monitoring, nutrition education, exercise; e.g., Wing, 1998), appetite awareness therapy (Craighead, 2006; Hill, Craighead, Smith, & Safer, 2006), self-help (e.g., Weight Watchers), online weight loss
programs, and antiobesity medication (e.g., orlistat, sibutramine).

CLIENTS WHO ARE CONCURRENTLY SEEING OTHER CLINICIANS
WHO LACK BACKGROUND IN TREATING EATING DISORDERS

Clients participating in our research trials were restricted from receiving concur—
rent psychotherapy from outside clinicians. In other settings, however, it may be
helpful to accept referrals from clinicians who do not have backgrounds in eating-disorder treatment and whose clients wish to receive a time-limited DBT for BED/
BN treatment to focus on their eating-disorder behaviors. In such settings, the
standard DBT case management strategy of consultation to the client would be
used. In coaching clients to manage their relationship with another clinician, DBT
therapists develop the client’s sense of control and self-effcacy and reinforce the
collegial nature of the therapist–client relationship.

IMPROVING DBT FOR BED/BN’S COST-EFFECTIVENESS

Treatment might be made more cost-effective by reducing the number of sessions.
Instead of 20, as researched in the DBT for BED/BN trials (e.g., Safer et al., 2001b,
in press; Telch et al., 2001), perhaps fewer sessions might deliver similar posttreat-

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

ment results. Such shortened treatments may be particularly helpful for less symp—
tomatic individuals, such as those meeting criteria for subthreshold BED or BN
(e.g., binge eating and/or purging one time per week on average versus two times
per week, as per DSM-IV-TR [American Psychiatric Association, 2000]). Other
ways to increase cost-effectiveness include delivering treatment via a self-help format or online. Less expensive online prevention programs utilizing DBT skills to
target individuals at risk for eating disorders should be considered.

It is hoped that this book’s availability will enable other researchers to rep—
licate and extend our work. The Appendix: Information for Researchers offers
details on the criteria used for recruiting participants for our randomized trials,
which assessments were administered, and the specifc content taught (e.g., skills
and worksheets) during each of the 20 research sessions.

APPENDIx

Information for Researchers

We have received multiple requests over the years for the treatment manual we developed
and used in our research studies. This Appendix is intended to provide information, in a
condensed format, on the criteria used for recruiting participants for our randomized tri—
als, to outline the assessment instruments, and to detail the session-by-session therapeutic
content (e.g., skills taught) and materials/handouts used.

INCLUSION AND ExCLUSION CRITERIA
Participants in the BED studies (Safer et al., in press; Telch et al., 2000, 2001) were required
to meet full DSM-IV-TR research criteria (American Psychiatric Association, 2000). Those
in the BN study (Safer et al., 2001b) were required to have had at least one binge–purge
episode per week over the previous 3 months.1

Exclusionary criteria were (1) BMI < 17.5; (2) current suicidality or psychosis; (3) current drug or alcohol abuse; (4) concurrent participation in psychotherapy or weight loss
treatment; (5) concurrent antidepressant or mood stabilizer use (Telch et al., 2001; Safer
et al., 2001b) or less than 3 months of stable antidepressant dosages (Safer et al., in press);
and (6) pregnancy or breastfeeding.

ASSESSMENTS

Participants were assessed at baseline, at completion of treatment, and at follow-up (e.g., 3
months, 6 months, 12 months).

The Eating Disorder Examination (EDE; Fairburn & Cooper, 1993) was administered
to determine the diagnosis of BED, BN, or partial BN and to assess the frequency of binge
and/or purge episodes.

1The rationale for using modifed DSM-IV-TR criteria was to broaden the study’s applicability. Commonly,
patients seen in general clinic settings complain of considerable bulimic symptomatology, but, not meeting
full criteria, they are often excluded from research. Eighty-one percent of the recruited participants met
full DSM-IV-TR criteria for BN.

The Structured Clinical Interviews for DSM-IV (SCID-I and SCID-II; First, Spitzer,
Gibbon, & Williams, 1995; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) were used
to assess current and lifetime Axis I and Axis II disorders at baseline. The Binge Eating
Scale (BES; Gormally, Black, Daston, & Rardin, 1982) was included as a measure of the
severity of binge-eating problems.

The Emotional Eating Scale (EES; Arnow et al., 1995) assesses the extent to which
specifc negative emotional states (e.g., anger, anxiety, and depression) prompt an individual to feel an urge to eat.

The Rosenberg Self-Esteem Scale (Rosenberg, 1979) measures beliefs and attitudes
regarding general self-worth.

The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh,
1961) reports the degree of symptoms of depression.

The Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988)
asks individuals to report the extent to which they recently experienced positive and negative emotions.

The Negative Mood Regulation Scale (NMR; Catanzaro & Mearns, 1990) measures
the participant’s expectancy that a behavior or cognition will alleviate a negative mood
state.

Weight and height were measured in lightweight clothing, with shoes removed.

SESSION-BY-SESSION CONTENT

Pretreatment Orientation
••
••

••

Emotion Dysregulation Model of Problem Eating (Chapter 3, Appendix 3.1)
Goals of Treatment, Goals of Skills Training, and Treatment Targets (Chapter 3, Appendix 3.2)

Group Member, Individual Client, and Therapist Treatment Agreements (Chapter 3,
Appendices 3.3–3.5)
Handouts Given at Each Session
Blank Diary Card (Chapter 3, Appendix 3.9)
Blank Chain Analysis (Chapter 3, Appendix 3.8)
Session 1

••
••
••
••
••

••

Pros and cons of binge eating (and purging)
Commitment to abstinence
Review path to mindful eating
Review Group Member and Therapist Agreements
Orient clients to diary card (Chapter 3, Appendices 3.9–3.10), chain analysis (Chapter
3, Appendices 3.6–3.8)
Skills: Commitment to abstinence, 3″
× 5
″
card

Session 2

••
••
••

Dialectical abstinence (Chapter 3, Appendix 3.13)
Review chain analysis (Chapter 3, Appendices 3.11–3.12)
Skills: Dialectical abstinence, diaphragmatic breathing

Appendix: Information for Researchers

Mindfulness Core Module
Session 3

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••