Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra L. Safer, Christy F. Telch, Eunice Y. Chen Page A

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

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    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.”