Dialectical Behavior Therapy for Binge Eating and Bulimia (48 page)

Th e r a p i sT: I am thinking that this skill might really help you right now. What do
you think about burning your bridges to stop binge eating and purging?
Cl i e nT: I’m scared. I’m still binge eating and purging every once in a while, which
is a real improvement. It’s hard to think of giving it up completely.

T
h e r a p i sT
: I noticed how scared you are, too. But what I am thinking is that in
order for you to gain confdence to deal with your fear without avoiding, we
have to see what life is like without this behavior. I want to be with you when
you do that—and we’ve got four sessions left to work on this together.
Cl i e nT: Well, the skills have worked when I have used them. But burning my
bridges feels a little like jumping off a cliff.

T
h e r a p i sT
: Can you tolerate that feeling and do it anyway?

Cl i e nT: I think I could. ... Oddly, I kind of feel excited. It seems like a second
chance at committing to stopping binge eating and purging.

Continuing with the case description of Sarah, Session 17 involved teaching
the Crisis Survival skills. Like many clients, Sarah expressed some apprehension
when introduced to the set of Self-Soothing skills.

sa r a h: I don’t really like to see my body or touch it with lotions. It doesn’t sound
very soothing to me.

Th e r a p i sT: Do you think you could give it a go just to make sure? Remember when
using this skill to try to really throw yourself fully into it One-Mindfully. If
your mind wanders to judgments about your body, for example, try to bring
your mind back to experiencing the moment, such as focusing on the smell of
the lotion or how it feels on your skin.

sa r a h: OK. Maybe I’ll surprise myself and enjoy it. And it makes sense that I need
to learn how to fnd things other than food soothing!

Review of Skills and Planning for the Future: Sessions 19–20

In Sessions 19 and 20, the therapist and Sarah reviewed skills from the three previous sessions. In addition, plans were discussed to help Sarah prevent relapses
once treatment ended. This involved having Sarah fll out a Planning for the Future
Homework Sheet (Chapter 7, Appendix 7.1) to discuss during the following session.

Illustrative Case Examples

In Session 20, when the therapist and Sarah reviewed her plan for the future,
Sarah identifed anger, hopelessness, and being ashamed as the emotions she found
most diffcult to tolerate and, therefore, most in need of a plan.

Th e r a p i sT: What did you write down as specifc plans for practicing the skills?
sa r a h: I’ve decided to photocopy the diary card so I can have it near my bed to fll
out every day. I think that would really help.

Th e r a p i sT: Fantastic! Anything else?

sa r a h: I’ve decided to take up yoga. I’ve always wanted to, and I think it would
help me to keep practicing the Mindfulness skills.

Th e r a p i sT: I agree! What about your plans for dealing with the specifc emotions
you mentioned?

sa r a h: For when I’m angry, my plan is to turn to diaphragmatic breathing frst,
as that has always helped. Then I would access my Wise Mind to help me not
to judge myself for how I feel. I also think Alternate Rebellion would help me to
fnd ways to express my anger without hurting myself. For hopelessness, I plan
to remind myself that I can Turn the Mind, I don’t need to capitulate, and I can
look at my diary card to remind me of all the skills I know now. And, fnally,
when I’m ashamed and feeling self-critical, I will use Radical Acceptance and
a nonjudgmental stance. I may continue to feel these feelings, but I want to be
aware of them. Also, from all the chains we did together, I think I’ve learned
that not being too hungry is really important for me. So no matter what diffcult emotion I’m experiencing, I would try to check out my vulnerabilities to
my Emotion Mind and keep working on getting enough sleep and trying not
to do it all.

Outcome of Treatment

Sarah’s primary treatment target was to stop binge eating and purging. The
information reported on the weekly diary cards indicated that after 5 weeks of
treatment, Sarah had ceased bingeing and purging, and she continued to be free
from objective bingeing and purging through the remainder of the 20 weeks. Dur—
ing the posttreatment interview, Sarah expressed appreciation for the treatment
approach and stated, “This therapy taught me skills that I can use in diffcult
times. The skills help me to stop and reevaluate all situations [and to] deal more
effectively with them.” At the end of treatment Sarah had gained 4 pounds from
her pretreatment weight. At 6-month follow-up, she reported two objective binges
and two purges since ending treatment (an average of one binge-and-purge episode
every 3 months). Sarah refected positively on her experience over these months
and explained that, rather than using food to help her manage her emotions, the
therapy had taught her to identify her emotions and subsequently to utilize skills
she had learned, such as diaphragmatic breathing, Wise Mind, and Radical Acceptance. Her weight was 114. However, she denied any feelings of dissatisfaction with
her weight and reported instead that she felt healthy and ft. Her low weight of 109
was not worth the emotional costs of binge eating and purging.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
UTILIZING DBT IN A GROUP FORMAT FOR CLIENTS WITH BED
Orientation to DBT: Pretreatment Interview and Sessions 1–2

Pretreatment Interview

The pretreatment interview, in which each prospective group member meets individually with one of the cotherapists, is similar to the pretreatment interview for
the BN case described. The purpose of the interview was to orient the group member to treatment, to describe the model of affect regulation, to emphasize the goals
and targets of treatment, and to review client and therapist agreements. In addi—
tion, the therapist should inquire about any prior experience in group therapy, go
over guidelines for the group to run smoothly, and address any concerns about
group treatment.

Commonly, very obese clients express the worry that they will be the heaviest
clients in the group, as in the following vignette:
Th e r a p i sT: Do you have any worries or concerns about being in the group that we
haven’t yet discussed?

Cl i e nT: Well, one thing I’m worried about is—will I be the heaviest one in the
group?

Th e r a p i sT: That’s a really important question. Our groups include people who are
a range of weights—from average to very overweight individuals. Although I
cannot tell you for certain the weights of all the individuals in the group at this
point, all of you will have something important in common. Everyone in this
group struggles with binge eating.

Cl i e nT: But people who are thin wouldn’t understand what it’s like.

T
h e r a p i sT
: It sounds like this feeling of not being understood could be one of the
emotional experiences that leads to binge eating for you. Everyone in the group
struggles with diffcult emotions and a sense of defeat regarding how to cope
without using food. So regardless of weight, the common factor binding the
group together is the recognition that binge eating is causing great harm and
the resolve to stop a behavior that only increases one’s suffering in the long
run. That’s why we focus on getting the binge eating under control frst and
foremost.

Session 1

A primary goal of the frst group session, as with the BN case presented, was to
motivate clients to commit to binge abstinence. Additionally, the frst session was
designed to review the biosocial model, to discuss the client and treatment agreements, and to orient clients to the diary card and chain analysis form. When treatment is delivered in a group format, group dynamics can infuence the process of
obtaining a commitment to binge abstinence. The following excerpt from one of our
group sessions illustrates a typical client with BED who was cautious about being
able to commit to stop binge eating.

Illustrative Case Examples

CoTh e r a p i sT
1: What do you think about the pros and cons we’ve listed so far?
Cl i e nT
1: I’m living on the con side, there’s no question about it. Because when I
was younger and doing ten times as much and raising a family, I had more
mental drive to make a change, and I could do it. I did a lot of things very
successfully. Now, as much as I want this, I don’t know if I can switch that on
again.

CoTh e r a p i sT
1: Sounds like you’re afraid this will just be another task to add to
your list, and you’re not sure you have it in you to give the amount of effort it
will take.

Cl i e nT
1: It does take a lot of energy, and it’s like your engine needs a tune-up or
something. You know, you just can’t foor it. ... I’ve lived with this for so long,
I’m fnding that I am really struggling with making this commitment.
CoTh e r a p i sT
1: It’s understandable that as you look back on diffculties you had
to contend with when you were younger and the amount of mental drive it
required, you feel hesitant to tackle another issue. However, the treatment is
designed to provide you with skills and tools that will eventually reduce the
struggle and offer you some peace.

Cl i e nT
1: Back then I didn’t have any skills. It was survival in a way. My motiva-tion was that I was raising two children and wanted them to grow up well,
have a happy home, be successful and so forth. ... I guess I had a payoff. But
now those things are done!

CoTh e r a p i sT
1: Sounds like when you put your mind to it, you can accomplish
goals that you value. What would be the payoff now?

Cl i e nT
1: That’s a good question. No one else is depending on me, it’s a personal
thing. I don’t feel the drive right now that I used to feel.

CoTh e r a p i sT
1: Any other thoughts, group?

Cl i e nT
2: Well, I think all the cons themselves are disgusting.

CoTh e r a p i sT
2: So that’s the payoff for you, to just get rid of the cons. (
To Client

1) It appears you’re fearful that there isn’t something strong enough to compel
you to change. Before, there were a lot of demands pressing on you and goals
for your family that drove you to stop back then. Whereas now, maybe you are
saying you’ve settled on a lower quality of life. You’re not sure whether you
have the inner “oomph” to do it—or ”foor it” as you said. It is scary to think
of trying to do this just for you. I mean it’s certainly hard to embark on something like this.

Cl i e nT
1: Well, you know, that’s a good point. Because it wasn’t ever about me, at
least not that I was aware of. It was always about something or someone else.

And now that those something elses have been taken care of, we’re back to the
bare roots now. What I was hiding behind by using the binge eating, overwork-ing, doing all those other things, I don’t know, but now, the fundamental issue
is still there.

CoTh e r a p i sT
1: Perhaps the fundamental issue is allowing something of value for
yourself, such as the skills we’ll be teaching. Taking in something that benefts

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
you in the long run and not approaching this from a pressured, demanding
stance but from a more generous mind-set.

At this point the therapists opened up the discussion to include other group
members’ thoughts about making their commitment to group abstinence.

Cl i e nT
3: I feel the need to get back control. Every so often I feel as though I’m
there but then I lose it. So I’m worried about being able to say I’m committed,
because I’ve said that to myself before, but then I worry I won’t stay with it.
CoTh e r a p i sT
1: That’s OK. What we’re asking you is to just stay in this one
moment. When you think of your goal or your intention, can you say at this
moment, “Yes, I am committed at this moment to do everything I can to stop
binge eating. That’s why I’m here.”