Dialectical Behavior Therapy for Binge Eating and Bulimia (6 page)

In developing standard DBT, Linehan synthesized her clinical and research
experience with BPD with principles and concepts from Western philosophy (dialectics), CBT, and both Eastern (Zen) and Western contemplative practices. DBT
may be thought of as a synthesis of these divergent ideas and the application of
this synthesis as a new means of treating emotional diffculties. DBT synthesizes
a focus on both change and acceptance in the skills that are taught in the treatment.

Since originally developing standard DBT in the 1980s, Linehan (1993a,
1993b) standardized DBT into two manuals. These manuals, which describe the
basics of dialectical philosophy, the therapeutic communication of both acceptance
and change, and the core assumptions of DBT, should be read before applying the
adapted treatment described in this book. As I worked to adapt DBT to eating
disorders, I received extensive consultation from Linehan. With Linehan’s permis—
sion, I “lifted” a great deal from Linehan’s manuals and transplanted it into my
original manual—Emotion Regulation Skills Training Treatment for Binge Eating
Disorder
(Telch, 1997a)—which serves as the basis for this book. Although each
of the authors of this book has added her own thoughts and made modifcations
targeting the content of DBT to eating disorders, it is accepted that the adapted
treatment presented is more or less an offspring of Linehan’s manual. Therefore,
Linehan’s manuals are not cited each time material from them is used.

BRIEF REVIEW OF EMPIRICAL EVIDENCE FOR STANDARD DBT

Standard DBT is currently the most strongly empirically supported affect regulation treatment for borderline personality disorder (American Psychiatric Asso—
ciation, 2001) and is regarded as the treatment of choice for this disorder (Lieb,
Zanarini, Schmahl, Linehan, & Bohus, 2004; Linehan, Comtois, et al., 2002). There
are multiple randomized controlled trials of standard DBT to date (Linehan, Arm—
strong, Suarez, Allmon, & Heard, 1991; Linehan et al., 1999; Turner, 2000; Koons
et al., 2001; Linehan, Dimeff, et al., 2002; Verheul et al., 2003; Linehan et al.,
2006) and a number of nonrandomized controlled trials (Barley et al., 1993; Bohus
et al., 2000; Stanley, Ivanoff, Brodsky, Oppenheim, & Mann, 1998; McCann, Ball,
& Ivanoff, 2000; Rathus & Miller, 2002; Bohus, Haaf, & Simms, 2004).

With standard DBT, compared with treatment as usual (Linehan et al., 1991)
or the more rigorous comparison of treatment by expert nonbehavioral therapists
(Linehan et al., 2006), suicidal clients with borderline personality disorder (1) were
signifcantly less likely to engage in suicidal behavior or nonsuicidal self-injury; (2)
reported fewer episodes of suicidal behavior or nonsuicidal self-injury; (3) had less
medically severe suicidal behavior or nonsuicidal self-injury; (4) were more likely
to remain in treatment; (5) had fewer inpatient psychiatric days; (6) reported less
anger; and (7) reported improved global and social adjustment at the end of treat-

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

ment. All clients improved over time, with reduced symptoms of depression, hope—
lessness, and suicide ideation (Linehan et al., 1991; Linehan, Heard, & Armstrong,
1993; Linehan, Tutek, Heard, & Armstrong, 1994; Linehan et al., 2006). These
fndings were maintained at 1-year follow-up (Linehan et al., 2006).

Randomized controlled trials utilizing DBT for the treatment of borderline
personality disorder and illicit substance use have also been effcacious (Linehan
et al., 1999; Linehan, Dimeff, et al., 2002). Both of these studies demonstrated
that participants assigned to DBT had signifcantly greater reductions in illicit
substance use compared with a control treatment (Linehan et al., 1999; Linehan,
Dimeff, et al., 2002).

INTRODUCTION TO TREATMENT MODEL, ASSUMPTIONS, AND RATIONALE

Before starting to work with clients using this treatment, therapists need to famil—
iarize themselves with the basic defnitions of emotion and emotion regulation as
understood in DBT. Briefy, emotions are powerful biologically based reactions that
organize our responses to internal and external stimuli. Emotions can be thought
of as complex phenomena that affect the total response of an individual. Emotions
have many “parts,” including, but not limited to, the emotional experience (e.g.,
fear), the emotional expression (e.g., running), and the physiological activity (e.g.,
sweating). Although these basic components are shared, individuals will, of course,
differ in (1) the intensity or strength of emotions; (2) the experience of positive and
negative emotions; (3) emotional lability (i.e., how emotions fuctuate); and (4) the
experience of particular emotions (e.g., shame, guilt). According to the DBT model,
emotion regulation involves attempts by the individual to infuence, change, or
control emotions either by preventing an emotion from getting started (e.g., avoid—
ing a feared situation) or by attempting to change the emotion once it has gotten
under way (e.g., escaping a feared situation). Adaptive emotion regulation requires
the ability to label, to monitor, and to modify emotional reactions, including the
ability to accept and tolerate emotional experiences when emotions cannot, in the
short run, be changed.

The theoretical model on which this treatment is based proposes that the core
problem for individuals with BED and BN is emotion regulation dysfunction. This
dysfunction is a result of both emotion vulnerability and inadequate skills for
adaptive emotion regulation. That is, this model posits that a central and primary
problem for these individuals involves defcits in labeling, monitoring, modifying,
and accepting emotions.

Because individuals with BED and BN have underdeveloped emotion regulation skills, they frequently rely on maladaptive means, such as binge eating and/
or purging, to control emotions. These behaviors may alter or infuence emotions
by distracting or suppressing emotional experience and expression, as well as by
calming physiological arousal. The temporary relief provided strengthens the
binge eating and/or purging as an emotion regulation strategy, and these behaviors become automatic, overlearned responses to emotion dysregulation, crowding
out more adaptive strategies. Binge eating and/or purging behaviors are maladaptive because they are harmful to the individual in the long run, exacerbating mal-

Orientation for Therapists

adaptive emotion regulation and profoundly interfering with physical, personal,
and interpersonal health.

This treatment is also based on the assumption that the emotion regulation
dysfunction evident in individuals with BED and BN is in part the result of emotional vulnerability. Emotional vulnerability is conceptualized as high sensitivity
to emotional stimuli, intense emotional responding, and a slow return to emotional
baseline. Individuals with BN report greater overall negative mood (Bulik et al.,
1996; Waller et al., 2003), and individuals with BED (Greeno et al., 2000) report
signifcantly more daily negative mood, as assessed on handheld computers, than
those without BED. There is supporting research evidence (Masheb & Grilo, 2006)
that individuals with BED and BN have emotion dysregulation across all emotions,
including positive emotions such as joy and excitement. That is, binge eating and/
or purging may be used to regulate strong feelings of excitement because, without
adequate emotion regulation skills, the excitement is experienced as overwhelming
and threatening. Finally, it is assumed that strong urges or impulses accompany
emotions for individuals with BED and BN, as well as strong bodily reactions (e.g.,
increased heart rate). Therefore, without the requisite emotion regulation skills,
individuals with BED and BN fnd it nearly impossible to refrain from acting on
strong impulses to binge eat and/or purge in the face of emotional distress.

Role of Invalidating Environments

This treatment model assumes that the transaction over time between emotional
vulnerability in individuals and the experience of a particular type of environment
produces the emotion regulation defcits seen BED and BN. This particular environment is described as invalidating and is characterized by a tendency to respond
negatively, inconsistently, and/or inappropriately to the individual’s private experiences (e.g., beliefs, thoughts, feelings, and/or sensations). For example, to control
the individual’s behavior, crying may be met with nonresponsiveness, punishment,
and/or criticism. Consequently, any expression of positive affect is not affrmed,
validated, or attended to. In such environments, children learn that certain emotions and private experiences are unacceptable and dangerous because they lead
to rejection, punishment, and disapproval.

The consequences of an invalidating environment during childhood develop—
ment can include (1) the inability to label feelings, (2) an inability to trust one’s
own emotions as valid interpretations of events, (3) an inability to tolerate distress
or adaptively regulate emotional arousal or emotional reactions, and (4) invalidation of one’s own experience. Self-invalidation teaches one to mistrust one’s internal
states and to rely on the environment for clues on how to respond. This tendency to
look for external validation leads to a failure to develop a sense of self. A core part
of eating disorders is a preoccupation with external sources to dictate one’s ideal
weight and shape.

The rationale for teaching adaptive regulation skills to individuals with BED
and BN should now be apparent. In order to stop using binge eating and/or purging
to regulate emotions, these individuals need to learn adaptive emotion regulation
skills that will replace the maladaptive binge eating. Otherwise, if such individuals stop binge eating and/or purging, another dysfunctional behavior may be sub-

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
stituted. This treatment also assumes that both acceptance and change skills are
essential for adaptive emotion regulation.

Treatment Goals and Targets

The goals of treatment, the goals of skills training, and the targets of treatment
are stated by the therapist in the pretreatment and frst sessions and are outlined
in a handout distributed during the frst session (Chapter 3, Appendix 3.2). Refer
to this material for further detail. Briefy, the primary goal of treatment is for
clients to stop binge eating (and purging) and to stop all other problem eating
behaviors listed in the target hierarchy (e.g., mindless eating, urges, cravings,
capitulating to binge eating). The goals of treatment are accomplished by teaching
the adaptive emotion regulation skills—Mindfulness skills, Emotion Regulation
skills, and Distress Tolerance skills. Clients are taught to practice and use these
adaptive Emotion Regulation skills to replace their maladaptive eating behaviors.

To accomplish these goals when we train our therapists, we teach them to
focus on several key points. For example, we advise them to always “keep your eye
on the prize”—that is, to remember that this treatment is aimed at stopping binge
eating (and purging).1
Therapists must be frm in their belief that binge eating is
a serious maladaptive and destructive behavior that must stop altogether. Therapists are constantly on the lookout for any behaviors that even slightly resemble
binge eating and work to help clients substitute the adaptive behaviors taught in
the treatment for the problem eating behaviors.

Keeping your eye on the prize requires therapists constantly to link the client’s
goals of gaining control over eating behavior, specifcally binge eating, with learning the skills. It is the therapists’ job to convince clients that learning and practicing the Emotion Regulation skills taught in the treatment is critical to achieving
their goals of stopping binge eating and gaining control over other problem behaviors. Additionally, it is imperative that therapists link the learning and practicing
of the adaptive skills with an enhanced quality of life. That is, binge eating and
problem eating behaviors produce guilt and shame and rob clients of their self—
esteem and sense of mastery and competence.