Dialectical Behavior Therapy for Binge Eating and Bulimia

Dialectical Behavior therapy
for Binge eating anD
Bulimia

Dialectical
Behavior therapy
for Binge eating
and Bulimia

Debra L. Safer
ChriSty f. teLCh
euniCe y. Chen

Foreword by
Marsha M. Linehan

THE GUILFORD PRESS
new york
l
ondon

A Division of Guilford Publications, Inc.
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LIMITED PHOTOCOPY LICENSE

These materials are intended for use only by qualifed mental health professionals.

The Publisher grants to individual purchasers of this book nonassignable permission
to reproduce all materials for which photocopying permission is specifcally granted
in a footnote. This license is limited to you, the individual purchaser, for personal use
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Library of Congress Cataloging-in-Publication Data

Safer, Debra L.

Dialectical behavior therapy for binge eating and bulimia / Debra L. Safer, Christy F. Telch,
and Eunice Y. Chen.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-60623-265-1 (hardcover: alk. paper)

1.
Compulsive eating.
2.
Bulimia.
3.
Dialectical behavior therapy.
I.
Telch, Christy
F.
II.
Chen, Eunice Y.
III.
Title.

[DNLM:
1.
Bulimia—therapy.
2.
Bulimia Nervosa—therapy.
3.
Behavior Therapy—
methods.
WM 175 S128d 2009]

RC552.C65S24 2009

616.85′26—dc22

2009006668

about the authors
Debra L. Safer, MD,
is Assistant Professor in the Department of Psychiatry
and Behavioral Sciences at Stanford University Medical Center. Dr. Safer obtained
her undergraduate and master’s degrees from the University of California, Berke—
ley. She attended medical school at the University of California, San Francisco,
followed by a residency in psychiatry at Stanford University. Her postdoctoral fellowship was also at Stanford, where she worked closely with W. Stewart Agras,
MD, and his eating disorders research team. Dr. Safer’s research and clinical work
focus on treating eating disorders in adults and adolescents utilizing dialectical
behavior therapy and other empirically validated treatments.

Christy F. Telch, PhD,
is in private practice in Palo Alto, California, where
she focuses on treating eating disorders as well as panic and anxiety disorders.
Dr. Telch obtained her undergraduate and master’s degrees in psychology from
California State University, Fullerton, and her PhD in counseling psychology from
Stanford University. She joined the faculty of the Department of Psychiatry and
Behavioral Sciences at Stanford, where she established a national reputation for
her research on eating disorders, authoring or coauthoring more than 30 journal
articles. In 1997, Dr. Telch received a grant from the National Institute of Mental
Health for the purpose of adapting dialectical behavior therapy for the treatment
of binge-eating disorder. The research she initiated with this grant and the treatment manual she wrote, Emotion Regulation Skills Training Treatment for Binge
Eating Disorder, are the basis for this book.

Eunice Y. Chen, PhD,
is Assistant Professor in the Department of Psychiatry and Behavioral Neurosciences at the University of Chicago, where she runs a
dialectical behavior therapy program for adults with eating disorders. Dr. Chen
received her undergraduate degree and PhD in clinical psychology from the University of Sydney, Australia. She subsequently completed postdoctoral fellowships
at Yale University and at the University of Washington, with Marsha M. Linehan,
PhD.

v

Foreword

S
ince the original manual for dialectical behavior therapy (DBT) was pub—
lished in 1993, there has been widespread talk about adapting the treatment for
different populations. I have urged researchers and clinicians to take care in how
they adapt DBT, specifcally, that they not reach beyond the data, that they stay
as close to the manual as possible, and that they conduct research on their adapta—
tions. Many people have been trying to adapt DBT for different populations, but
very few have done so with the diligence of Debra Safer, Christy Telch, and Eunice
Chen. Dialectical Behavior Therapy for Binge Eating and Bulimia
is, to date, the
only DBT treatment manual for eating disorders that has data from randomized
controlled trials to support it.

Christy Telch approached me in 1994 about adapting DBT for binge-eating
disorder. She frst wanted to ensure that she was competent in standard DBT
before adapting the treatment, so she began supervision with me. Christy is one
of those rare people who understands DBT from the inside out. She not only has a
grasp of the strategies and principles of DBT, she also understands its nuances and
has incorporated them into this book.

Debra Safer, an important member of a committee for strategic planning of
DBT research that I formed several years ago, soon became involved in developing
the book. Debra understands both eating disorders and DBT and has a passion for
ensuring that this book stays true to the data and the treatment.

Eunice Chen joined the Behavioral Research and Therapy Clinics (BRTC) at
the University of Washington in 2002 as a postdoctoral fellow. She has become an
expert in eating disorders, especially as they are part of complex, multiple-problem
patients. While at the BRTC, Eunice studied DBT and eating disorders as well as
borderline personality disorder (BPD). She has since left the BRTC and moved to
the University of Chicago, where she is doing exciting research with various eating
disorders, BPD, and DBT.

Every week, we feld phone calls and e-mails from people who are looking for
innovative ways to treat eating disorders. Most clinicians and researchers have
believed that DBT could be adapted for eating disorders, especially when the dis-vii

viii

Foreword

ordered eating behaviors were the consequence of emotion dysregulation. Safer,
Telch, and Chen are the frst to do so with an empirical basis. Prior to the release of
this book, many clinicians have been using the standard skills training handouts
with people with bulimia and binge eating. This book provides over 30 handouts
that remain true to the original DBT skills, but are written to address eating
behaviors. The case examples are tailored to bingeing and bulimic behaviors and
will guide clinicians and researchers in providing DBT.

As you read this book, there are several important things to consider. First,
this is not the treatment manual for complex, suicidal patients. The data for suicidal patients still support standard DBT. Second, this book is for stage 3, single—
problem patients. It is skills training group based and is tailored for patients with
bulimia and binge eating. Third, this book does not currently have data for treat—
ing anorexia. As always, it is important to follow the data.

Best wishes in your efforts to provide and research DBT.

Ma r s h a
M. L
i n e h a n, PhD

Professor, Department of Psychology

Director, Behavioral Research and Therapy Clinics
University of Washington

acknowledgments

W
e are deeply grateful to the many individuals who have helped to make this
book a reality, including those serving as therapists on our research trials: Brenda
Brownlow, PhD, Emily Hugo, PsyD, Rebecca Klein, PsyD, and Susan Wiser, PhD;
those serving as research assistants over the years: Wanda Chui, Sara Clancy,
Molly McMillen, Shireen Rizvi, PhD, and Amanda Vaught; and the many doc—
toral students who assisted with the project, among them Maggie Chartier, MPH,
Megan Jones, Megan McElheran, and Nicole Riddle. Others who made signifcant
contributions are W. Stewart Agras, MD, Jennifer Couturier, MD, Kara Fitzpat—
rick, PhD, Craig Forte, LCSW, Eval Gal-Oz, PhD, Gerry Gelbart, MD, James
Gross, PhD, James Lock, MD, PhD, and Lynda Malavanya, MD.

We also wish to thank Shari Manning, PhD, of Behavioral Tech Research, Inc.,
for her generosity in both reading the manuscript and offering valuable feedback.
We acknowledge, with gratitude, our debt to Marsha M. Linehan, PhD, whose own
work inspired this adaptation and whose encouragement motivated us to publish.
And we have been immensely fortunate to have Kitty Moore as our editor at The
Guilford Press; her expert guidance is felt throughout this book.

Debra L. Safer would also like to thank her loving family, with special gratitude to Dan and Elaine, her parents; her husband Adam and their daughter, Zoe;
and Vilma, their indispensable nanny.

Christy F. Telch would like to personally thank Drs. W. Stewart Agras, Bruce
Arnow, and Marsha M. Linehan for their encouragement, support, and wise coun—
sel throughout the process of conducting this work. Additionally, she would like to
express her heartfelt appreciation to her loving husband, Bob Forman, and dear
sons, Aaron Telch and James Forman, for their generosity of spirit and unending
patience throughout her work on this project and her career.

Eunice Y. Chen would like to thank Mike McCloskey and Sunny Koey for their
love and support.

Finally, all of us want to specially acknowledge and thank all the clients who
participated in our research trials over the years. Without you, this book would
never have been possible.

ix

contents

Chapter
1.
Binge-eating Disorder and
Bulimia
n
ervosa: