Dialectical Behavior Therapy for Binge Eating and Bulimia (41 page)

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Overview of Crisis Survival Skills

Give an overview of the Crisis Survival skills that will be taught: Distraction skills,
Self-Soothing skills, skills for Improving the Moment, and skills that help clients
Think of the Pros and Cons of tolerating their distress. The reason for so many different types of skills is that surviving an emotional crisis takes a great deal of skill
and effort. Different situations warrant the use of different skills. Having as many
different Crisis Survival skills in one’s toolbox as possible is an advantage because
one can draw from them as needed.

Underscore the importance of maintaining an open mind while practicing these
skills, as clients never know what exactly might be effective. Therapists make clear
that, of course, the skills that will be mentioned are not an exhaustive list. Clients
can add to it things that would be helpful to them. The one criterion for a Crisis
Survival skill is that it helps the client survive the crisis without making things
worse. It shouldn’t be something that ends up allowing one to shoot oneself in the
foot.

DISCUSSION
P
OINT:

“What are situations you need to ‘survive’ in your life right now?”

Distraction Skills

The purpose of these skills is to temporarily reduce clients’ contact with emotional
triggers or situations that are too overwhelming. Therapists explain that in such
situations, clients need to refocus outside of themselves and outside of the situations they are in in order to give themselves a much-needed break. The idea is to
interrupt the crisis long enough to reduce their tension, so that when the clients
return to the crisis they are at least a little bit renewed or have a slightly different
perspective.

One category of distraction skills involves distracting oneself with activities,
such as exercise, hobbies, cleaning, going to events, calling and visiting with a
friend, and so forth. Another category includes distracting by contributing. The
idea here is that by contributing one gets in touch with a different experience from
that of the current crisis. Many clients report this skill to be very useful to them.
The contribution does not have to be a big one. It might involve saying hello to
someone. Another type of distraction involves making comparisons. It can be helpful to think of others who are experiencing a worse situation or who are less fortu—
nate. Therapists acknowledge that doing this can initially be a bit off-putting for
some but that clients should try to keep open minds. Therapists might educate clients about research on the phenomenon of a “downward comparison” that suggests
that comparing oneself with individuals worse off than oneself can improve one’s
mood. Reiterate that the reason so many skills are presented is to allow clients to
fnd one or more that will work for them in a certain situation.

Another way to distract oneself is by bringing up opposite emotions. By becom—
ing involved in something that will result in a different and positive emotion rather
than an upsetting one, clients can distract themselves. Some suggestions include

Distress Tolerance Skills

watching comedies (e.g., movies, TV shows), listening to soothing or uplifting
music, reading a funny book—anything that will get clients involved in a different
emotional experience.

Clients can also distract themselves through pushing away, or leaving the situation. If possible, this can entail physically removing oneself for a period, which
can be incredibly helpful. If clients cannot leave physically, they might try “leaving” mentally—perhaps by envisioning boxing up the overwhelming situation or
feelings and putting the box high on the shelf. Again, the purpose of this skill is to
help clients take a temporary break.

Another means of distracting is the use of other intense situations. For example, clients might stand under a very hot shower, immerse their faces in ice water
(many fnd this particularly effective at triggering a calming response), hold ice
cubes in their hands, listen to very loud music, and so forth. Clients should be
encouraged to do things that distract them from whatever the emotional trigger is
so that they can experience something different.

It is important to remind clients to practice Crisis Survival skills One-Mindfully. These skills often will not work if clients are practicing a Crisis Survival skill
while simultaneously thinking about the crisis.

DISCUSSION
P
OINT: “Do you have examples of times when you’ve distracted yourself?

When did you? How well or not did it work? Are there other types of distractions that
have not been mentioned that you do or have done in the past that are effective?”

Self-Soothing Skills

When clients are emotionally overwhelmed, the thing for them to do is to comfort,
nurture, and be gentle with themselves. Therapists might point out that clients
would likely suggest this strategy to someone else undergoing a crisis, but, com—
monly, when people face crises themselves, kindness either does not come to mind
or they are actively criticizing and berating themselves for experiencing the crisis
and/or for not being able to resolve it. Yet having compassion for oneself is key.

The skill of Self-Soothing can be organized by the fve senses to make it easier
for clients to remember. When practicing self-soothing with vision, clients might
buy a beautiful bouquet of fowers, light a candle, visit a museum flled with beautiful art, look at nature, and/or go out in the middle of the night to watch the stars.

When practicing this skill, clients should incorporate the Mindfulness skills,
such as being mindful of each sight that passes in front of them. In other words,
by putting themselves in the state of mind of acceptance, of being in just this
one moment, clients may fnd it easier to get through a crisis without making it
worse.

When clients self-soothe with hearing, they might try listening to beautiful,
peaceful music, or they might practice paying attention to the sounds of nature
around them, such as the chirping of birds and crickets. Clients might also hum a
soothing song to themselves (e.g., a favorite tune or a lullaby). Therapists should
emphasize that self-soothing music should not include music that triggers problem
behaviors (e.g., music that one associates with binge eating and/or purging).

DIALECTICAL BEHAVIOR THERAPY FOR BINGE EATING AND BULIMIA
Self-soothing can also involve the client’s sense of smell. Clients might use
their favorite lotions or perfumes, light a scented candle, boil cinnamon, and/or
mindfully breathe in the fresh smells of nature.

With some clients with eating disorders, self-soothing with taste
will work
well, but not with others. If a client decides to practice self-soothing with taste,
using her or his Wise Mind to help decide, the practice should involve tasting
and/or eating mindfully. Potential ways to practice might include having a soothing hot drink, such as a cup of favorful tea, sucking on a piece of candy, treat—
ing oneself to a single portion of a tasty dessert, putting whipped cream on one’s
coffee, and so forth. Encourage clients to really taste and savor the food they are
eating.

Clients choosing to practice self-soothing with touch
might take a bubble bath,
have a massage, treat themselves to a manicure or pedicure, pet their dogs or cats,
soak their feet, put a cold compress on their foreheads, or cuddle under a soft or
heated blanket.

DISCUSSION
P
OINT: “Do you tend to ignore your sensations when in a crisis? Would
these skills, designed to help you be gentle with yourself, be useful to you for everyday
crises, as well as for especially diffcult times?”

DISCUSSION
P
OINT:

“Have you tried these types of things? Can you imagine doing so?”

Improving the Moment

The Crisis Survival skills of Improving the Moment are intended to help clients
stay in just the moment they are in, making that moment more palatable than
it would be otherwise. Although just that one moment is improved, clients may
fnd that having this new experience breaks up the unrelenting nature of the crisis, helping them to survive the situation they are trying to bear without making
things worse by engaging in self-destructive behaviors such as binge eating.

Improving the Moment with
imagery
includes visualizing relaxing scenes,
imagining coping well, and so forth. Encourage clients by informing them how
effective the use of imagery can be as a tool. Therapists must be careful, however,
to remind clients that this skill can be particularly diffcult to access during a
crisis, particularly without prior experience. Therefore it is very important to gain
practice using imagery during nonstressful periods.

Improving the Moment with meaning
involves clients fnding or creating some
purpose, meaning, or value in the diffcult experience they are having. Therapists
might point out that it is essentially making lemonade from lemons.

Improving the Moment with prayer
is very helpful for some clients. This means
of improving the moment involves opening one’s heart to a greater wisdom, to one’s
own Wise Mind—or whatever prayer means to the client. The prayer might involve
asking for the strength to bear one’s pain.

Distress Tolerance Skills

Improving the Moment with one thing in the moment
involves focusing atten—
tion on just the one thing that you are doing in the current moment. This is basi—
cally the practice of Mindfulness. Because life is made up of a series of moments,
reminding yourself to stay in just the moment you are in can make it easier to bear
the pain rather than focusing on how long the crisis has already lasted or project—
ing how long it will continue to last.

Improving the Moment with a brief vacation
includes activities such as taking
a blanket to the park and sitting on it for a few hours; giving yourself a day to turn
off your phone (including your cell phone or personal digital assistant) and letting
the answering machine take the calls; going to the movies for an afternoon; and so
forth. It is important for the therapists to remind clients that, as always, they must
take into account what will be effective for them. Some individuals practice taking
a vacation too often during a crisis, essentially using it as an ongoing escape. This
skill, therapists clarify, is meant more for those whose tendency is to stay with the
crisis or confict until it ends, refusing any break at all. For them, especially, taking a breather can be very effective.

Improving the Moment with encouragement
includes saying things to oneself
such as “I can stand this,” “This won’t last forever,” “I will make it,” and/or “I am
doing the best I can.” Any type of cheerleading or inner reassurance is a very effective way of Improving the Moment.

DISCUSSION
P
OINT: “What thoughts, comments, or reactions do you have to the
Improving the Moment skill?”

Therapists might use the following exercise to help clients experientially practice a Crisis Survival skill, modifying it as needed.

ExPERIENTIAL
Ex
ERCISE:
CRISIS
S
URVIVAL
S
KILLS

“Get comfortable in your chair, your feet on the foor, your posture erect, and choose
a place for your eyes to focus. Breathe several deep breaths from your diaphragm.
Bring to mind a crisis of some sort—either one you are currently experiencing, one
you have experienced in the past, or one you can imagine occurring in the future.
Then imagine using one of the Crisis Survival skills. Perhaps you’d choose a Dis—
traction skill, something to temporarily reduce your contact with the overwhelm—
ing situation. Perhaps an activity, contributing, or doing something that brings up
an opposite emotion? Or imagine Self-Soothing—being compassionate with yourself and doing something that pleases one of your senses. Or perhaps Improve the
Moment you are in by using imagery or fnding meaning in the situation. Remem—
ber, these skills won’t solve the crisis, but they are ways to shore up oneself in order
to bear pain more effectively.”