Dialectical Behavior Therapy for Binge Eating and Bulimia (2 page)

Why Dialectical Behavior therapy?

5

Chapter
2.
orientation for therapists

16

Chapter
3.
the pretreatment Stage: the pretreatment interview

and
i
ntroductory Sessions

30

Chapter
4.
mindfulness core Skills

89

Chapter
5.
emotion regulation Skills

120

Chapter
6.
Distress tolerance Skills

155

Chapter
7.

final Sessions: review and relapse prevention

179

Chapter
8.
illustrative c

ase e
xamples

190

Chapter
9.
future Directions

215

appenDix.

information for researchers

223

references

229

index

237

xi

This book was written in response to repeated requests from therapists in the clin—
ical and research community for a detailed description of how dialectical behavior
therapy (DBT) has been adapted to treat binge-eating disorder (BED) and symptoms of bulimia nervosa (BN). The aim of this book is to make available a compre—
hensive presentation of this promising treatment.

The treatment program is based on the original manual written by Christy F.
Telch (1997a). This program has been tested and shown to be effcacious in a number of research studies conducted at the Department of Psychiatry and Behavioral
Sciences at Stanford University (Safer, Robinson, & Jo, in press; Safer, Telch, &
Agras, 2001a, 2001b; Telch, 1997b; Telch, Agras, & Linehan, 2000, 2001).

The program described in this book is an adaptation of standard DBT, a treatment originally developed by Linehan (1993a, 1993b) for individuals engaging in
recurrent suicidal behavior who meet criteria for borderline personality disorder.
This adapted version for eating disorders involves a number of modifcations to
standard DBT that refect the differing client populations and research questions.
For instance, standard DBT was developed to address the severity and potential
lethality of behaviors commonly associated with borderline personality. A year—
long treatment, standard DBT includes weekly individual psychotherapy, weekly
group skills training, access to 24-hour telephone coaching, and a weekly consulta—
tion team for therapists.

Our adapted version of DBT is aimed at clients whose BED or BN symptoms
are the primary focus of treatment. This adapted version combines elements of the
functions of two distinct modalities in standard DBT: individual psychotherapy
(enhancement of motivation) and group skills training (acquisition/strengthening
of new skills). These are delivered in 20 weekly sessions, a 2-hour group format
for clients with BED or a 1-hour individual format for clients with BN symptoms.
In addition, this adapted version of DBT includes three of the four skills training
modules of standard program DBT (Mindfulness, Emotion Regulation, Distress
1

2

Tolerance). The rationale for excluding the Interpersonal Effectiveness skills mod—
ule was based on clinical trial design concerns regarding potential overlap with
other treatments developed for BED and BN that specifcally focus upon treating
interpersonal problems.

FOR WHOM IS THIS BOOK WRITTEN?

We have written this book for a variety of different audiences. For therapists with
training in DBT but little experience with treating disordered eating, this book is
intended to provide pertinent eating-disorder background, as well as specifc direc—
tion for applying DBT with clients whose primary presenting symptoms are binge
eating or bulimia. For therapists familiar with treating clients with eating disorders but not with DBT, this book outlines the basic principles of DBT with a focus
on how these are adapted for individuals with binge-eating and purging problems.
For investigators interested in researching DBT as adapted for BED and BN, we
hope that the detailed description of this treatment modifcation will increase its
use, encourage program improvements, and further treatment evaluation efforts.

One important note of caution. By documenting DBT adapted for BED and
BN, we do not wish to convey an oversimplifcation of the treatment or the problems it is intended to address. The issues our clients face are complicated, and
DBT is a multifaceted treatment approach. In order to ensure competent delivery
of this treatment, we recommend a sound background in general cognitive-behavioral principles and an understanding of standard DBT. We consider Linehan’s
two manuals,
Cognitive-Behavioral Treatment of Borderline Personality Disorder
(Linehan, 1993a) and
Skills Training Manual for Treating Borderline Personality
Disorder
(Linehan, 1993b), to be companion texts to this book and recommend that
they be read prior to embarking on this treatment.

WHAT TYPES OF CLIENTS MIGHT MOST BENEFIT

FROM RECEIVING THIS TREATMENT?

This treatment was originally developed and studied in an outpatient setting in
which clients with BED received weekly group sessions and clients with bingeing
and purging symptoms received weekly individual sessions. Applying the treatment in similar settings with similar clients would have the greatest likelihood
of reproducing the positive outcomes originally found. Clinicians and researchers
interested in using or evaluating this treatment in other contexts, such as a partial
hospital or inpatient ward setting, will probably need to make further modifca—
tions.

The research support for DBT adapted for BED and BN, although promising,
is relatively limited. Thus, we advise proceeding with the use of this treatment
after carefully considering the available alternatives. The most conservative recommendation at this time is that DBT as adapted for binge eating and bulimic
behavior may be most appropriate for clients who have undergone the standard,
evidence-based eating-disorder treatments (e.g., cognitive-behavioral therapy or
interpersonal psychotherapy) and failed to improve or received minimal beneft.

To date, research has not identifed the relevant variables for matching clients
and DBT adapted for eating disorders in order to produce the best outcomes. There—
fore, until such research is conducted, we can only speculate about the factors that
might suggest a good match between the treatment described in this book and a
particular client. For instance, the treatment model underlying this adapted DBT
approach posits a primary link between affect dysregulation and binge-eating or
bulimic behaviors. For a client struggling with emotional eating who describes
binge-eating episodes clearly triggered by negative emotions (e.g., anger, sadness),
this treatment may be particularly suitable. Anecdotally, we have found that clients who report that the Emotion Regulation model of binge eating fts their own
personal experience seem to do particularly well.

CLIENTS WE RECOMMEND NOT RECEIVE THIS ADAPTED DBT TREATMENT

It is not unusual for clients seeking treatment for BED or BN to suffer from comorbid conditions such as mood disorders (e.g., Berkman, Lohr, & Bulik, 2007;
Telch & Stice, 1998) and Axis II disorders (e.g., Cassin & von Ranson, 2005). Data
from our own treatment studies demonstrate signifcant improvement in target
symptoms in clients despite substantial comorbidity rates for depression, anxi—
ety, substance abuse, and personality disorders (see Table I.1). With clients with
multiple symptoms, it is always advisable to prioritize treatment targets. Accord—
ingly, if other serious behaviors, such as current substance abuse or dependence
or suicidal behaviors, are present, we recommend postponing the use of DBT for
BED or BN treatment until the eating-disorder symptoms are the appropriate primary treatment target (Chen, Matthews, Allen, Kuo, & Linehan, 2008). That is to
say, we would not recommend this adapted DBT approach for clients with severely
chronic multiple symptoms who are also actively suicidal or who have borderline
personality disorder or combined borderline personality disorder with substance
dependence. For these individuals, the standard DBT program has a number of
randomized clinical trials (Linehan, Armstrong, 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;
TABLE I.1.
Rates of Comorbid Psychopathology among Clients
in Randomized DBT for
BED Study

Comorbid condition
Percentage (%)

Major depression (current)

Major depression (lifetime)

Anxiety disorder (current)

Anxiety disorder (lifetime)

Substance abuse/dependence (lifetime)
Personality disorder

9
38
18
35
27
27

Note. Data from Telch, Agras, and Linehan (2001).

4

Bohus, Haaf, & Simms, 2004) attesting to its effcacy. The original comprehensive
multimodal DBT program would be the treatment of choice for such clients. Simi—
larly, individuals with active substance abuse or dependence may be best directed
to a specifc substance abuse or dependence treatment.

There are also currently no published empirical data examining the effcacy of
this program for clients meeting criteria for anorexia nervosa, although there are
programs adapting DBT for these individuals (Wisniewski, Safer, & Chen, 2007).

ORGANIZATION OF THIS BOOK

This book consists of nine chapters. The frst chapter familiarizes readers with the
many problems faced by people with BED and BN, gives an overview of currently
available treatments, and provides the rationale and existing evidence for adapting
DBT for BED and BN.

Chapter 2 orients therapists to DBT for BED and BN. It explains the impetus
for developing this adapted treatment; includes a brief review of standard DBT’s
empirical evidence; introduces the treatment model, assumptions, goals, and tar—
gets; and describes basic therapist strategies and specifcs regarding how sessions
are structured.

Chapters 3 to 7 describe the “nuts and bolts” of how DBT was adapted to treat
BED and bulimic symptoms. Chapter 3 focuses on the pretreatment and intro—
ductory sessions. The Mindfulness module is outlined in Chapter 4, the Emotion
Regulation module in Chapter 5, and the Distress Tolerance module in Chapter 6.
Chapter 7 describes treatment termination and relapse prevention.

Chapter 8 uses two case examples, one of a client with BN and another of clients with BED treated in a group format, to illustrate the delivery of the treatment
and common issues that arise.

Finally, Chapter 9 outlines future directions for DBT for BED and BN.

The Appendix at the end of the book offers detail on criteria used for recruiting
participants for our randomized trials, the number and type of diagnostic assess—
ments, and specifcs regarding the therapeutic content (e.g., skills taught) during
each of the 20 research sessions.

A WORD BEFORE WE GET STARTED

We recommend that therapists planning to deliver this treatment should do two
things (in addition to reading Linehan’s manuals). First, we recommend reading
the entire book prior to conducting treatment with clients, paying close attention
to the treatment rationale and treatment goals as described in Chapter 2. Second,
before teaching the skills to others, therapists should have practice using each
of the skills on their own. Therapists should continue to practice the skills when
delivering the treatment and engage in “homework” practice of the specifc skills
that are the focus of the session.