Dialectical Behavior Therapy for Binge Eating and Bulimia (9 page)

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
the client analyze what happened, what interfered, and how the client can be more
effective with the use of skills the next time.

Therapists should watch for any clients who always use the same skill. In such
cases, remind clients that the objective is to develop the ability to use each skill.
Once a skill is learned, clients can choose not to use it. But experience with all the
skills allows clients to make informed decisions about whether or not a particular
skill is best for them given the circumstances.

In summary, problems that come up in the homework review can be addressed
by briefy:

1.
Formulating hypotheses about the possible factors involved in producing
the problem behavior.

2.
Generating skills solutions by asking, “What skills could you have used
here?”

3.
Encouraging group members to commit to trying out the skills solutions
suggested.

In our research setting, at the end of the review of skills practice, therapists collect
any diary cards, homework sheets, chain analyses, and so forth.

Break

During 2-hour group sessions, a 5-to 8-minute break should take place after the
homework review to allow group members to use the restroom, get a drink of water,
stretch, and so forth. Inform the group members that the second half of the session
will begin promptly to allow a full hour during which instruction and practice of
the new skills can take place.

Skills Instruction

In general, teaching each skill involves:
1.
Providing an explanation or rationale for including the skill in this treat-ment program—that is, explaining to clients why this skill is being taught,
why it is important, and how it is relevant to clients’ goals of stopping binge
eating and gaining control over problem eating behaviors.

2.
Skill acquisition—describing the skill and specifc steps for learning the
skill.

3.
Skill strengthening—demonstrating how to practice the skill and providing
opportunities to practice that skill during the group sessions.

4.
Skill generalization—providing suggestions for using skills during daily
life. Therapists should enlist clients in generating ideas about how skills
can be used to replace binge eating and other problem behaviors when emo-tions are dysregulated.

The teaching of skills is facilitated by the use of handouts and homework mate—
rials. The idea is to make learning the skills relevant to clients’ lives. To make sure

Orientation for Therapists

group members are active and involved in the discussion, therapists should ask
questions that check for skill comprehension and to enlist ideas for skill utilization.
To facilitate comprehension, therapists should focus on making a few key points,
using the remainder of the time to illustrate with metaphors and stories, to rein—
force, or simply to rephrase those key points.

At the end of the session, therapists should clarify and review the homework
for the upcoming week. This involves describing homework sheets and making sure
clients understand how to practice and record the skills. Then, during the session’s
fnal minutes, a wind-down is offered. This involves a few minutes of practicing a
specifc skill (e.g., diaphragmatic breathing).

In conclusion, there is a great deal to cover in each session, with very little
time to do so. Therapists must therefore be fexible, using skillful means to be
effective rather than trying to be perfect. When necessary, therapists must be will—
ing to give up making each and every point during instruction of a skill if the
situation calls for spending more time on a client’s question. Alternatively, if the
therapist feels the skills training will suffer as a result of omitting a point, the
therapist might offer to discuss the question over the break. The idea is to always
keep one’s eye on the prize—helping clients stop binge eating by teaching adaptive
skills when emotions are dysregulated.

CHAPTER
3

The Pretreatment Stage
The Pretreatment Interview and Introductory Sessions
T
his chapter describes how the pretreatment stage is conceptualized and
structured in DBT for BED or BN. The overall goals of this stage are to (1) orient the client to treatment, (2) obtain the client’s agreement to treatment, and (3)
obtain the client’s commitment to abstinence from binge eating (and purging). In
our research, this stage begins after we complete the diagnostic assessments and
determine the client to be eligible for entry into the study.

When treatment is conducted in a group format, the orientation stage includes
(1) a pregroup pretreatment interview (conducted individually with each group
member in the 1–2 weeks prior to the start of the group) and (2) introductory sessions conducted in the group format. In our research studies of 20 sessions, these
introductory sessions usually are covered during the frst 2 weeks of treatment.
When therapy takes place in an individual-session format, a pretreatment interview is also necessary. One of the goals of the pretreatment interview—obtaining
a commitment to coming to treatment—is essential to establish before obtaining a
commitment to stop binge eating and/or purging. The purpose of the next session,
what we term the introductory session, is a more involved elicitation of a verbal
commitment to stop binge eating (and purging). However, if constraints of a par—
ticular clinic setting are such that a separate pretreatment session is not feasible,
the pretreatment interview goals and materials may be combined in an initial session, with the commitment to treatment attendance a prerequisite to addressing
the commitment to abstinence from binge eating (and purging). Nonetheless, it is
our experience that separating the functions of the pretreatment and introductory material into distinct sessions is desirable when conducting treatment in an
individual-session format, as this gives the therapist adequate time to underscore
the importance of the commitments and the treatment without feeling rushed and
potentially covering the material in a cursory fashion.

The Pretreatment Stage

The pretreatment interview has a number of important and specifc goals. Usually
requiring 30–45 minutes, it is not intended to replace a standard clinical intake
(e.g., history of present illness, past psychiatric and medical history, social history) but is scheduled after such diagnostic assessment has been completed. The
goals of the pretreatment interview are presented here and discussed in greater
detail in the relevant subsections in this chapter, as well as in the case examples
in Chapter
8.

Goals of the Pretreatment Interview

The seven goals of the pretreatment interview follow.

1.
Develop a therapeutic alliance.

2.
Gain an understanding of the client’s overall eating diffculties.
3.
Provide clients with a rationale for DBT treatment.

4.
Orient clients to treatment and obtain commitment.

5.
Review treatment expectations for the client and the therapist.
6.
Provide logistical information and opportunity for questions.
7.
Convey enthusiasm.

Especially in settings in which the diagnostic assessment has been conducted
by a member of the team other than the therapist (e.g., research assistant, study
physician), the pretreatment interview may be the frst opportunity for the therapist to actually meet the client. The most important goal of this meeting is for the
therapist (or cotherapist when treatment is in a group format) to begin to develop
a therapeutic alliance. The second goal of the pretreatment interview is to provide
the therapist with an opportunity to gain a general picture of the client’s diffculties with eating. In the case of Sarah, age 36, in Chapter 8, her binge eating and
purging tended to occur during evenings when her husband traveled and she had
been particularly stressed supervising her two children’s homework and getting
them ready for bed.

The third goal is to provide a rationale for the treatment the client is about
to commence. This involves introducing the client to the Emotion Dysregulation
Model of Problem Eating (Appendix 3.1), with the therapist assessing the model’s
personal relevance and ft for the client.

The fourth goal involves orienting the client to the treatment’s goals and tar—
gets and obtaining the client’s commitment to these. This includes a discussion of
the concept of treatment-interfering behavior (e.g., not coming to therapy). Obtaining a commitment to treatment attendance sets the stage for addressing treatment-interfering behaviors should they emerge. The ffth goal is to review treatment
expectations for both the client and the therapist. These are listed in Appendices
3.3–3.5. The sixth goal is to provide practical information, such as the dates and
times of treatment, and to give the client an opportunity to ask questions. Typical
questions posed by clients are described later. The seventh and a fnal goal of the
pretreatment interview is to provide the therapist with the opportunity to convey

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
enthusiasm about the start of treatment and the client’s participation. The therapist’s conviction about the value of the treatment and confdence in the client’s ability to succeed increase the chance of a constructive start to treatment—flled with
positive expectations and hopefulness.

Orienting the Client to the Pretreatment Interview and Dates of
Treatment

Therapists begin the pretreatment interview by introducing themselves. Make
sure to express enthusiasm even during this frst meeting, perhaps saying some—
thing such as: “I’m very happy you’ll be joining us. We’re all so excited about this
treatment approach.” Explain that the purpose of the pretreatment interview is
to get to know the client and to provide an overview of the treatment program, as
discussed later.

From the outset, it is important to underscore the link between commitment to
the course of treatment and the client’s ability to overcome her or his binge eating
(and purging) behaviors. For example, the therapist might say:
“We know that it is very important to you to stop binge eating [and purging]
and to gain control over your eating behaviors. Your accomplishing these goals
is very important to us, too. One thing we assume is that if you could change
these behaviors on your own, you would have done so by now. To give this treatment a chance to work, you’ll need the full course. It is crucial to commit to
coming to each session even when you don’t feel like it—especially then!—or
it is particularly inconvenient. You might think about it as being prescribed
a certain amount of antibiotics to take if you’re ill. It is important to take the
whole dose, even if some days you don’t feel like it or are feeling as if you don’t
need it. It takes a lot of effort to stop binge eating [and purging], and we want
you to succeed, so receiving a full dose of the treatment is important.”

Discussing Dates of Treatment and Making Up Missed Sessions
During the pretreatment interview, the therapist should review the client’s avail—
ability for the scheduled period of treatment. In our research studies, clients, during the assessment period, compared their schedules with the dates of scheduled
sessions. Clients who, at the outset of treatment, determined that they would have
to miss more than three group sessions were unfortunately not able to join the
group.1
Of course, in individual treatment, scheduling can be more fexible, but
every attempt should still be made to keep treatment as continuous as possible,
with missed sessions rescheduled quickly. If sessions are carried out in a group
format and are recorded on audio or video, the therapist explains at this juncture
(to be revisited as needed subsequently) that clients who cannot avoid missing
sessions (e.g., due to illness) are required to set up a time to make up the missed
material by coming to listen to the recordings.