Dialectical Behavior Therapy for Binge Eating and Bulimia (28 page)

The following experiential exercise is an opportunity to practice Mindful Eating with a typical binge food. Clients frst practice this imaginally. The skill of
One-Mindfully is being highlighted, but the skills of Observe, Describe, and Par—
ticipate (at least imaginally) are also being practiced. The script can be modifed
as needed.

ExPERIENTIAL
Ex
ERCISE:
IMAGINAL
M
INDFUL
E
ATING

“Begin by fnding a place for your eyes to softly focus that won’t distract you. Let
the chair fully support you, with your feet on the foor and your head aligned as if a
string were attached from it to the ceiling. Take several deep, fowing breaths and
bring to mind a food that you might typically binge on, if you have a typical food.
Perhaps pizza, ice cream, chips, or whatever. Bring your full attention, your undi—
vided attention, to just this food, as we did with the raisins. Smell the food, look
at it, observe its colors. Take one chew at a time, experience one favor at a time,
with your full attention on the act of eating, on chewing. If your mind wanders,
just bring it back to the activity you’re engaged in, just eating. Stay with the eating, one small swallow at a time. You might be aware of thoughts that this doesn’t
taste good or, as many of you described when you practiced mindful eating, that you
didn’t really want it. But the point is to have a full awareness of eating.”

DISCUSSION
P
OINT: “What was your imaginary Mindful Eating like? Are you willing to eat
this way in reality?”

Effectively

Introduce the last “How” skill, Effectively, by explaining that this skill involves
focusing on doing what works, on being effective. Therapists make clear that being
right, being correct, or being perfect are not the issue. The idea is to do what is
effective to achieve one’s goal. Effectively means playing with the cards you are
dealt rather than folding. Effectively means playing by the rules, even if clients do
not like the rules or are afraid of them. Practicing being effective is the absolute
opposite of cutting off your nose to spite your face.

Therapists bring up how, at times, practicing Effectively means that one has
to give in instead of insisting that things go the way one wants them. Indeed,
insisting that things go a certain way, that that is the only right way, is a kind of
digging in that can often propel one into Emotion Mind and into binge eating and/
or purging and other problem eating behaviors. Clients may
be right; the client’s
way might indeed be
the fair way. But when clients rigidly adhere to something
that isn’t in line with the present reality, things just will not work. Being effective
requires accepting reality as it is and acknowledging the situation as it is, not the
situation the way clients think it should be. Things are not always fair.

Therapists might use the example of imagining what would happen if a client visits a busy city and decides that because people should
be trustworthy, one
should not
have to lock one’s car and
should
be able to leave packages inside it

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
while going for a walk in a nearby park. If one’s goal is to eventually take one’s
purchases home, would this likely be an effective action?

Effectively means focusing on what one’s goals are, such as wanting to enjoy
one’s purchases or wanting to stop binge eating (and purging) and other problematic
eating behaviors. Clients are thinking about what is effective rather than insisting
that the world or their bodies be different from what they are. This includes letting
go of binge eating (and purging), because this behavior is not effective. Instead,
what is
effective is getting in touch with one’s Wise Mind and being mindful of
consequences.

DISCUSSION
P
OINT: “Can you think of a time when you were shooting yourself in the
foot in some way and that escalated your emotions and led to binge eating and/or
purging?”

TROUBLESHOOTING
D
IFFICULTIES
IN
T
EACHING
THE
“H
OW” SKILLS

••
Example 1: “I’m too busy not to multitask!”

••
Potential therapist reply: “I can so relate to that! You have to use your Wise
Mind. I’m not saying that change is easy. It could feel excruciating at times. But if
you’re going to be different, change is required.”

••
Example 2: “Doing things One-Mindfully sounds so diffcult!”

••
Potential therapist reply: “People describe a lot of different experiences when
practicing the skill of One-Mindfully. People often worry that if they experience
an emotion One-Mindfully, then that means the experience will never change. For
example, if they’re experiencing fear, then they’ll be stuck in the fear forever. But it
is the nature of experience that experience changes.”

SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to complete the Mindfulness “How” Skills Homework
Sheet (Appendix 4.6).

Urge Surfng

Therapists introduce this skill by explaining that Urge Surfng uses the Mindfulness skills of Observe and Describe to “surf” out urges to binge (and purge), preoccupations with food, and cravings. Mindful Urge Surfng involves a mindful nonat—
tached observing of these urges. With this skill, clients are learning to accept the
urges, cravings, and preoccupations without reacting to them, judging them, or,
particularly, acting on them. Clients can simply observe and describe the ebb and
fow of their urges. They are detaching the urge from the object of the urge—the
food. Instead of engaging in eating the food and/or purging it, they are to practice
observing and describing their urges.

Mindfulness Core Skills

Make clear that the idea is for clients to use Urge Surfng to train their brains
not to respond to urges, as they had done previously. In other words, when they gave
in to their urges and binged or engaged in other problematic eating behaviors, they
reinforced the link between having an urge and acting on it. Urge Surfng involves
retraining their brain. Over time, by Urge Surfng urges, cravings, and preoccupa—
tions, the brain learns that it is possible to experience an urge without acting on
it. Therapists explain that clients may fnd it helpful to think of Urge Surfng as
being similar to surfng or riding out a wave. The wave is the urge. Instead of try—
ing to stop its movement, clients can surf on top of it. In doing so, clients are using
the skills of Observe and Describe to stay with the experience without succumbing
to it. Clients should notice the urge moment by moment, particularly how, like a
wave, it evolves and shifts over time. The key to Urge Surfng is the stepping back
and not reacting. The following experiential exercise allows clients to practice Urge
Surfng with a food that many fnd tempting. Modify the script as needed. Begin
this exercise by handing out malt balls (or other type of tempting candy).

ExPERIENTIAL
Ex
ERCISE:
URGE
S
URF
WITH
M
ALT
B
ALL

“Take one of the malt balls but do not eat it. First, look at the malt ball, or, alterna—
tively, imagine some other food you fnd more tempting. Smell it, be aware of any
salivation. Be mindful of any thoughts, feelings, or judgments that arise. Be very
aware of any urges to eat the malt ball. Again, the idea is to stay with the urges without eating. Just be open to whatever comes to mind. Just urge surf, riding the urge
out. Use Observe, Describe, Nonjudgmentally, and One-Mindfully with all that you
experience—any thoughts, sensations, feelings, or judgments you experience as you
are aware of the malt ball. You may want to visualize the malt ball as though it were
a picture of a malt ball instead of the actual food in front of you. Imagining food as
a picture of the food can be helpful to separate yourself from it. You are not reacting
to the urge. At the end of this exercise, get in touch with your Wise Mind to decide
whether to eat the malt ball or not. If you choose to eat it, do so as a conscious choice
to eat it—and do so mindfully. If you choose not to eat it, be mindful of that choice.”

TROUBLESHOOTING
D
IFFICULTIES
IN
T
EACHING
U
RGE
S
URFING

••
Example: “With Urge Surfng, are you saying we’re on the waves or some—
where else—observing them?”

••
Potential therapist reply
: “The image of a wave is a metaphor for the experience one has when one is caught up in one’s emotion and is noticing a strong pull
to act in a way that is consistent with that emotion. You’re imagining that you are
surfng the urge as if it were a wave. You’re watching it rise higher and higher, and
then start to fall. It may seem as if it never stops rising, but it
will
always fall. In a
sense, in order to surf, you do have to be riding your board on top of the wave while
at the same time observing your stance with respect to the wave. But I suppose you
could also step back and watch yourself Urge Surfng the waves.”

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
SUGGESTED
HOMEWORK
P
RACTICE

Therapists instruct clients to fll out the Urge Surfng Homework Sheet describing
their practice of this skill over the following week or until the next session (Appen—
dix 4.7).

Alternate Rebellion

Introduce this skill by explaining that many clients with eating disorders describe
their binge eating as a wish to rebel or “get back” at those who have been judg—
mental about their weight and/or eating—such as friends, family members, and
society in general. Alternate Rebellion is the skill of satisfying this wish to rebel
without destroying the client’s overriding objective, which is to stop binge eating
(and purging). Alternate Rebellion involves rebelling Effectively. As the therapist
describes, it involves fnding a way to honor the urge to rebel creatively instead of
attempting to suppress or judge it or to mindlessly give into it by binge eating or
other problematic eating behaviors.

Therapists may fnd it helpful to elicit reasons that binge eating (and purging) is not an effective strategy for rebelling in that clients’ overall objectives for
obtaining a higher quality of life are not kept in mind. With Alternate Rebellion,
the idea is to try to fgure out how to satisfy the urge to rebel in a manner that
honors it and the client. Alternate Rebellion can also replace the target behavior
of capitulating—of shutting down the option to not binge (and purge). Make clear
that there are many ways to employ this skill, and invite clients to use their imagi—
nation. For example, clients who feel very judged by others about what they eat
might effectively rebel by going to an ice cream store, ordering one cone, and eating it mindfully, without hiding, rather than buying a pint at a grocery store and
eating it secretively at home. Some clients describe effectively practicing Alternate
Rebellion by buying sexy lingerie that faunts and celebrates their bodies exactly
as they are. Others have practiced Alternate Rebellion by writing a letter to someone that says every single thing they want to say with no censoring—then burning
the letter.

Therapists might point out that many clients with eating disorders give themselves a list of rules about how they must look or what they must eat and then fnd
themselves acting as if those rules were actually someone else’s. In such cases,
clients are really rebelling against their own rules. An Alternate Rebellion, in
such cases, might be to let go of overly rigid rules. If a client is exhausting him-or
herself by insisting that project after project be completed, for example, an effective Alternate Rebellion might be to sleep in! The key is to use Wise Mind. In some
cases, Wise Mind might say that another skill might be more effective for experi—
encing the urge to rebel rather than acting on it. But if Wise Mind decides to honor
the rebellion, then the key is for the client to act in such a way that they will not
harm themselves.