Dialectical Behavior Therapy for Binge Eating and Bulimia (8 page)

Motivation and Commitment Strategies

Eliciting commitment and agreements from clients is an ongoing task for therapists throughout treatment. The frst agreement clients make is to come to treatment. The next is to agree that the goal of treatment is to stop binge eating, and
the next is to learn and practice the skills. Therapists constantly gauge a client’s
level of commitment, using motivation and commitment strategies as commitment
waxes and wanes.

In DBT, motivation is not viewed as an internal state or an intrinsic quality
of the client. Instead, therapists understand the necessary role of situational vari—
ables that, when present, increase the likelihood that clients will exhibit a desired
behavior (i.e., be “motivated”). Therapists also keep in mind that eliciting commitment and agreement from a client is an ongoing job that requires therapists to constantly gauge the client’s current level of commitment, returning to the motivation
and commitment strategies as the client’s commitment waxes and wanes.

In standard DBT, group skills training focuses on remediating clients’ defcits
in capability, whereas individual treatment helps clients identify applications of the
newly taught skills to everyday situations and also involves analyzing motivational
issues that may interfere. This analyzing may take the form of a behavioral chain
analysis or a solution analysis, or it may involve using commitment strategies.

The challenge for therapists conducting this adapted DBT treatment is to pro—
vide in one session both the motivational component usually focused on during
individual treatment in standard DBT and the skills training usually taught in
group skills training (see also Chapter 3). It is the job of therapists to cheerlead
clients in using skills in diffcult situations. When clients give up, the therapist
should not assume that clients either can or cannot solve problems for themselves.

Orientation for Therapists

Wherever possible, the therapist needs to work on “dragging out” new behaviors in
clients in these situations.

Commitment strategies are discussed briefy here and throughout the relevant
sections of this book. Again, readers are also referred to Linehan’s text (1993a,
particularly pp. 284–291) as essential reading. Evaluating Pros and Cons involves
helping the client review the advantages of whatever behavior is being evaluated,
as well as counterarguments to those advantages. The therapist should highlight
the short-and long-term consequences of the pros and cons. For example, behaviors that look attractive in the short run may have very negative sequelae. In Play—
ing the Devil’s Advocate, the therapist counters or challenges the client in a way
that results in the client’s providing his or her own reasons that he or she must
change. In the Foot-in-the-Door technique (Freedman & Fraser, 1966), the therapist enhances compliance by frst asking for something easy, followed by something
more diffcult. In the Door-in-the-Face techniques (Cialdini et al., 1975), the therapist frst makes a challenging request followed by an easier one. In Connecting
Present Commitments to Prior Commitments, the therapist reminds the client of
previously made commitments to bolster a commitment that may be waning or
when the client is behaving in ways that are inconsistent with previous commitments. The strategy of Highlighting Freedom to Choose in the Absence of Alternatives enhances commitment by emphasizing the client’s choice to do whatever he or
she wishes while highlighting the lack of effective alternatives.

Treatment Team Consultation Strategies
The primary strategy here is a weekly meeting of therapists. The purposes of these
team consultation meetings are (1) to review and evaluate adherence to the proto—
col; (2) to “treat the therapist” by providing a nonjudgmental environment for each
therapist to observe and describe his or her own behavior, thoughts, and feelings
regarding the week’s sessions and for other team members to provide nonjudgmental feedback, validation, and suggestions for change; and (3) to discuss how best
to handle any therapy-interfering behaviors on the part of any group members or
clients receiving individual therapy.

Structural Strategies

Treatment is structured or organized around the specifc targets outlined in the
treatment target hierarchy (Chapter 3, Appendix 3.2). The targets include both
problem eating behaviors that must stop and the skills that must be learned in
order to accomplish this. By orienting clients to the skills being taught and how to
use them, the therapist bridges the gap between the client’s goal of stopping binge
eating and the client’s learning of the new skills. For example, the therapist might
say: “OK—so this is what you can do when you’re feeling depressed if you don’t
want to feel that way. Opposite action means doing the opposite of what your mood
is telling you to do. So the opposite of depression—which tells you to withdraw and
to stay inactive—is getting active.” Therapists give clear instructions as to how
clients can apply the skills being taught rather than assuming that clients possess
this ability.

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA

STRUCTURE OF GROUP SESSIONS

As described briefy, this adapted treatment combines elements of the functions
of two distinct modalities in standard DBT: individual psychotherapy (enhance—
ment of motivation) and group skills training (acquisition/strengthening of new
skills).2
With much to accomplish, each 2-hour weekly group session should start
on time, whether or not all group members are present. Therapists begin by greet—
ing the group. If a group member arrives late or has missed a previous session,
she or he is asked to briefy state what occurred as part of her or his turn during
the homework review. This attention to behavior that interferes with receiving
treatment is very important, and absences or late arrivals should not be ignored.
But after this brief attention, therapists should move on. If a group member is
not present and is expected, one of the cotherapists may call to check in and
encourage the client to attend the group. With clients who are repeatedly absent
or late, group leaders should use their judgment and may wish to address this
privately with the group member in a brief phone call or an in-person meeting. If
necessary, a chain analysis will be performed targeting this therapy-interfering
behavior.

Homework Review: Diary Cards and Chain Analyses

Chapter 3 discusses the structure of the homework review in greater detail. Briefy,
the frst half of each session (50 minutes for group sessions, 25 minutes for individual sessions) is devoted to a review of the past week’s skills practice and chain
analyses conducted on targeted behaviors. In the group format, each group member should have about 5 minutes to report on her or his use of the new skills and to
describe specifc successes or diffculties in applying the skills to replace problem
eating behaviors. The therapists check with each group member to make sure she
or he can explain what skills were used, how she or he used them, and whether
they were effective. Group members should be encouraged to help one another iden—
tify solutions to problems encountered in applying the skills and to “cheerlead” the
efforts each fellow group member makes.

Therapists clearly convey that each group member will be asked about her or
his skills practice and that the member will be questioned about skills not practiced. This serves to motivate clients to use the skills at some point during the
week so as to have something to share. Clearly stating that each member will be
asked to share each week sets the norm for practice and can be a source of motivation. Therapists should be alert to the possibility of a group member feeling “stu-2Although our data are based on the structure used in our research trials, wherein BED treatment was
delivered over 20 weekly 2-hour group sessions and BN treatment over 20 weekly 50-minute individual
format sessions, there are no data to suggest that changing the delivery method would adversely affect
clinical outcomes. Indeed, Telch’s case report (1997b) demonstrated good response in a client with BED
receiving treatment via individual sessions. Therefore, therapists treating individuals with BED or BN
may administer the treatment in either a group or individual format. Similarly, although our research
studies tested 20 treatment sessions, differences between research and clinic settings may require therapists to cover the material at a different rate. Chapters 3–7 focus on the skills to be taught, not on the time
allotted for the therapist to teach them. For therapists wishing to replicate our studies, the appendix to this
book outlines the specifc content covered in each session.

Orientation for Therapists

pid,” ashamed, or embarrassed about sharing and can discuss which of the skills
would be useful to practice in this circumstance.

Because a very limited amount of time is available, therapists should help clients to be very focused. Chapter 3 offers more guidance. Briefy, clients are asked
to report on two items. The frst is a report of their practice of the skills during the
prior week and their use of skills to replace maladaptive binge eating and other
problem eating behaviors. The basis for this sharing about skills practice is the
diary card, which each client is expected to have completed. The second item is the
client’s report on the chain analysis conducted on the targeted eating behaviors.
Each client reports on the target behavior highest in the hierarchy (Chapter 3,
Appendix 3.2). For example, if binge eating and/or purging—the highest targets—
occurred, the client must report on the chain analysis of that behavior. If binge eating and/or purging occurs, it is important for therapists to keep in mind the con—
cept of dialectical abstinence (Chapter 3) to help clients fail effectively so that they
can get back up and make a commitment to never binge again from this moment
on. If binge eating and/or purging did not occur, the next target on the hierarchy
would be discussed.

In the homework review, the client is asked to report on (1) a key dysfunctional
link identifed on the path to the problematic behavior (see Chapter 3 for details)
and (2) what skill or skills they could have used and will try to use next time to
replace that dysfunctional link.

For clients having diffculty with skills practice and application, therapists
need to assess the nature of that diffculty. For example, frst determine whether
the problem is due to a lack of understanding of the skill, to a lack of skill practice, or to motivational factors. If the problem is due to a lack of understanding, a
brief review—ideally offered by another group member—may be indicated. If the
client understands the skill, determine whether greater strengthening is needed
through additional practice. If so, help the client to set realistic practice goals. If
the problem is due to a lack of motivation, the commitment strategies described
earlier and given in greater detail in Chapter 3 (and see also Linehan, 1993a) are
utilized. For instance, the therapist may have the client review pros and cons of
practicing skills, form a plan of action to practice skills, and commit to the plan to
overcome obstacles to skills practice (including self-criticism for lack of practice)
for the upcoming week. Therapists must be careful not to join in punishing or
criticizing the client but help her or him to recommit to practice. Therapists should
describe and validate any successes described, as well as failures. This may mean
validating how diffcult it can be to use the skills under extremely stressful condi—
tions. If therapists are judgmental about group members’ diffculties, clients may
feel free to share only successes.

Therapists may suggest to clients who repeatedly fail to practice the skills that
they use the chain analysis form to analyze this problem. In other words, lack of
skills practice is the targeted problem (treatment-interfering behavior) analyzed
in detail via a chain analysis. Conducting a chain analysis is a skilled behavior in
and of itself, and helping clients to develop this skill is key to adaptive behavior.

Therapists must search for and praise every small approximation of using the
skills. For example, therapists can distinguish between the client’s attempts to use
the skills and the outcome. Praise should be offered for effort, followed by helping