Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra L. Safer, Christy F. Telch, Eunice Y. Chen
Tags: General, Social Science, Medical, Psychology, Psychotherapy, Psychopathology, Psychiatry, Nursing, Eating Disorders, Psychiatric, Social Work
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weight weekly to allow evaluation of any changes in weight that coincide with treatment.
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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
23
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
22
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
23
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
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