Dialectical Behavior Therapy for Binge Eating and Bulimia (7 page)

Keeping your eye on the prize also requires therapists to adopt the notion of dialectical abstinence. This is described in the second session (Chapter 3, pp.
65–67).
Briefy, the essence of dialectical abstinence is that therapists must, simultane—
ously, outwardly convey a frm conviction that each client in the program can and
will stop binge eating while inwardly being poised and ready to “catch” clients
when they fail and binge eat. Therapists must be absolutely certain that binge
abstinence can be achieved and that clients can immediately stop binge eating at
the start of the program. Therapists convey the attitude that this is essential and
that there can be absolutely no middle ground. Clients must stop binge eating now
in order to gain control over their lives. Of course, it is the therapists’ job to help
1Although only binge eating is usually referred to throughout the remainder of the text, purging and
any other compensatory behaviors (e.g., laxative abuse, fasting, overexercise)—when present—are always
assumed to be an additional target.

Orientation for Therapists

clients fgure out what to do in order to stop binge eating and to replace this behavior with adaptive behaviors, and, in this, therapists are very active in prescribing
specifc skills for clients to engage in to replace binge eating. Therapists provide
the momentum, the conviction, the “jump start” until clients can continue this
movement on their own. On the other hand, therapists are simultaneously ready to
“pick clients up” when they fail. Therapists help clients learn how to fail well. That
is, although therapists convey the conviction that clients can and must stop binge
eating, therapists nonjudgmentally accept clients who fall short of this and engage
in binge eating. Therapists respond to binge eating by acknowledging that binge
abstinence is hard while maintaining the conviction that the client can achieve it.
After a client breaks binge abstinence, therapists explain that the task now is to
accept the disappointment, learn from the failure, and commit from this moment
on to repair the self-harm done by never again binge eating.

Keeping your eye on the prize requires attention to the number-one treatment
target listed on the target hierarchy—to stop any behavior that interferes with
treatment. Therapists are clear with clients that they believe that binge eating
and problem eating behaviors will not stop without treatment. Therefore, because
the clients’ goals are to stop binge eating and to gain control over their eating and
their lives, clients must receive treatment to achieve these goals. If clients are not
in treatment, they are less likely to get better. Any behavior that interferes with
receiving treatment (e.g., absences, late arrivals) are top priority, and therapists,
at the onset of treatment, elicit a commitment from clients to address any treatment-interfering behaviors. Once this is made clear, therapists do not need to refer
to this again unless treatment-interfering behavior arises.

Within our research trials, a fnal requirement of keeping your eye on the
prize has been that therapists adhere to the treatment protocol described in this
book. For example, at the trials run at Stanford, we emphasized to therapists that
teaching the skills prescribed is absolutely nonnegotiable. What is negotiable is
how they are taught. That is, the strategies used to present them must be employed
fexibly. Therapists must decide, when delivering the treatment, whether or not a
particular strategy is appropriate to use given the context of what is taking place
in the session. For example, the book may suggest using the devil’s advocate strategy to enhance client commitment, but given the context of that particular group,
Extending may be more appropriate. The strategies or tools used to teach the skills
are negotiable and therefore may be used fexibly.

It is important to point out that clients, particularly those with BED, will likely
express concern about whether or not treatment is aimed at losing weight. Therapists must validate that this is an understandable concern, one that is shared by
the therapists, who are also concerned about the client’s weight to the extent that
excess weight refects maladaptive eating behaviors. However, therapists must
make clear that this is not specifcally a weight loss program in that diet, nutrition,
and meal prescriptions are not a treatment focus. It is assumed that clients who
learn and use the adaptive skills for regulating emotions taught in treatment will
stop binge eating and gain increased control over their eating in general, and as a
result their weight may decrease (also see Chapter 3). Clients are asked to moni—
tor their weight weekly to allow evaluation of any changes in weight that coincide
with treatment.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

DELIVERING THE TREATMENT: BASIC THERAPIST STRATEGIES

DBT for BED/BN utilizes the same treatment strategies as standard DBT (Line—
han, 1993a, 1993b). These include its use of dialectical strategies (e.g., balancing
validation and change, modeling dialectical thinking), problem-solving and solu—
tion-analysis strategies (e.g., chain analysis), stylistic strategies (e.g., irreverence),
commitment strategies (e.g., Evaluating Pros and Cons, Playing Devil’s Advocate,
Foot in the Door, Door in the Face, Connecting Present Commitments to Prior
Commitments, Highlighting Freedom to Choose in the Absence of Alternatives,
and Cheerleading), structural strategies, and treatment team consultation strategies (e.g., weekly meetings of therapists).

These treatment strategies are described briefy here and given greater detail
at relevant points in subsequent chapters.

Dialectical Strategies

DBT is based on a dialectical worldview that stresses the fundamental interrelat—
edness or wholeness of reality and connects the immediate to the larger contexts of
behavior. From a dialectical worldview, reality is not seen as static but as compris—
ing opposing forces (thesis and antithesis) out of which synthesis can evolve, gener—
ating a new set of opposing forces. The individual is stuck in polarities, unable to
move beyond the confict, and the therapist assists the client to resolve the dialectical dilemma or confict and move to a synthesis. The synthesis is a different way of
being, a different perspective that moves beyond the confict. From this viewpoint,
the fundamental dialectical strategy used by therapists is to stay aware of the
polarities the client is stuck in and suggest ways out (e.g., use of skills).

The primary dialectical strategy for therapists to focus on when delivering
this treatment is the balance between acceptance and change. The essential “attitude” of therapists that pervades this treatment is one of sensitivity to the balance
between the need for clients to accept themselves just as they are and the need for
them to change. This dialectic is clearly represented by the concept of dialectical
abstinence. The guiding principle of dialectics is also refected in the skills taught,
including both Radical Acceptance and Loving You Emotion—in addition to skills
for changing emotions. The therapist must both accept and validate the current
circumstances of the individual while simultaneously teaching behavioral skills
that deliver the message that things must change.

The therapist balances pushing the client toward change in order to have a
better life and holding the client with an acceptance of how the client is in the
moment. In this context, the therapist must be acutely aware of the client’s ten—
dency toward imbalance in either leaning too far toward pushing for change or not
changing despite change being needed. It is the job of the therapist to provide the
balance. The aim is to help clients become comfortable with change and to accept
change as part of reality.

The dialectical attitude toward acceptance and change is conveyed in part by
the therapist’s balanced application of both validation and problem-solving strategies. The essence of validation is the communication that a response is understand—
able in the current context. Given the current set of circumstances and the client’s

Orientation for Therapists

learning history and belief structure, the therapist recognizes and communicates
that the client’s response makes sense and is valid. Validation is not sugarcoating,
whitewashing, or reassuring. For example, if the client claims: “I’m so stupid to
have let my boss get to me so that I ended up going home and binge eating after
work,” validating this client would not mean saying, “You’re not stupid.” Validating
would involve acknowledging the client’s experience of feeling stupid, comment—
ing that it is both understandable that the client responded as she or he did and
that she or he feels stupid in hindsight. Validating does not include validating the
invalid. So in this case the therapist would not want to validate binge eating as an
effective response to emotional distress.

In a nutshell, a dialectical treatment approach (1) searches for synthesis and
balance to replace the rigid and dichotomous responses characteristic of dysfunc—
tional individuals and (2) enhances clients’ comfort with ambiguity and change,
which are viewed as inevitable aspects of life.

Of the many dialectical strategies (see also Linehan, 1993a, Ch. 7, pp. 199–
220), two others noted here are Extending and Making Lemonade Out of Lemons.
In Extending, which is based on aikido, the therapist stays with a client rather
than opposing him or her and then takes the client one step further so that the
client is thrown off balance and is more open to new direction. The essence of
Making Lemonade Out of Lemons is making opportunities out of diffcult situ—
ations. As Winston Churchill reportedly said, “The pessimist sees the diffculty
in every opportunity. The optimist sees the opportunity in every diffculty.” It is
important to convey that one can learn from mistakes. For example, individuals
with BED and BN often feel demoralized and flled with shame after a binge, with
a tendency to avoid thinking about the episode. In such an instance, the therapist
acknowledges the “lemons” while also utilizing the experience as an opportunity
to understand the antecedents to the problem behavior and to identify effective
skills to be employed next time. Therapists should look for multiple opportunities
to employ this strategy and help clients learn to pick themselves up from “failures”
by turning the failures into learning experiences.

Problem-Solving and Solution-Analysis Strategies

Problem-solving strategies involve a two-stage process of, frst, accepting that there
is a problem and, second, generating alternative adaptive responses. This means
that the therapist frst helps the client to observe and describe in a nonjudgmental manner the problematic binge-eating and impulsive-behavior patterns. Second,
following the nonjudgmental analysis of the problem eating behavior, the therapist helps the client to generate alternative effective and adaptive solutions. This
involves identifying skills that have been taught and working on client motivation
to use the skills.

Problem-solving and solution-analysis strategies are woven throughout this
treatment and involve a detailed examination of the problem behavior accompanied
by the generation of alternative adaptive responses. The use of a detailed chain—
analysis monitoring form in this treatment (see Chapter 3, Appendix 3.6) helps
clients to identify the events and factors leading up to and following the targeted
problem behavior. The solution analysis involves the identifcation of alternative

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
adaptive responses (i.e., identifying skills to use). The chain-analysis monitoring
form is completed by the client for each instance of targeted problem behaviors and
reported on during the homework review section of the session.

Stylistic Strategies

Therapists conducting this treatment balance a responsive and empathic communication style conveying warmth and understanding with an irreverent style
delivered in a matter-of-fact manner. One or the other is used moment to moment
in sessions, depending on what the situation calls for. Responsive, empathic communication is usually most appropriate when assisting the client to accept him-or
herself and to help him or her to move out of negative self-judging. The matter-of-fact communication is a strategy to help get a client who seems unable to see things
from a different perspective to become “unstuck.” The irreverent communication
strategy is designed to gently shock or wake the client up by being quite frank and
honest with her or him, thus helping the client to get moving. For example, if a client says “I couldn’t keep practicing the skills because they were taking too much
time,” the therapist, with a humorous tone, may say, “Ah—I get it. Practicing the
skills took up too much time ... but you were
able to ft in time for a binge,” or “If
you had time to binge, you had time to practice the skills.”